NCC214368_Notice of Termination_20221018

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 10/18/2022 8:58:58 AM (NOT Submittal)
Approve by Clark, Paul B 11/14/2022 2:16:46 PM (NOT Request Review - NCC214368)
* 9/1/2022 - invoice due date, 10/18/2022 - request submitted, waive fee, rescind COC
• The task was assigned to Clark, Paul B by round robin distribution 10/18/2022 8:59 AM
The task was assigned to DEMLR NCG01 NOT Review Team. The due date is: October 21, 2022 5:00
PM 10/18/2022 8:59 AM

Use this form to submit a Notice of Termination (NOT) request for a project covered under the N.C. NPDES
General Permit for Construction Activities NCGO10000 (or NCG250000). If approved, the Certificate of Coverage
(COC) will be rescinded.
Certificate of NCC214368
Coverage (COC) No.* Enter the Certificate of Coverage Number
2020 Annual Fee Status 2021 Annual Fee Status 2022 Annual Fee Status
May be blank if N/A May be blank if N/A WAIVED
May be blank if N/A
Information associated with this permit:
Project Name Odessa Drive Distribution Center Phase 1
Lots Covered by this This information is especially helpful when more lots were added with Modifications since the original permit
Permit COC (if
issuance.
applicable)
No longer visible on the initial form (data not captured from initial application)
Address
Odessa Drive, Statesville, NC
County
Iredell
Latitude
35.8180
Longitude
-80.8580
Permittee Listed
ITAC 469, LLC
Legally Responsible
Victoria Templeton
Individual
NC Reference No.
NCG01-2021-4368
E&SC Plan ID
STVLE-2022-005
Original NOI Tracking
60316
No.
Date COC Issued
8/2/2021
Prior Rescission Date
Date populates only if COC was already rescinded at time of submittal.
Reason for Rescission/Termination Request:
Reason for Project Closed -Out
Termination of Sale (Another Owner/Operator obtained new COC)
Coverage* Mistake or Invalid Coverage
Other
New owner/operator NCC223587
COC No. Enter the COC number obtained by the new owner

New Owner Name First and last name
4077 Industrial Park, LLC
New Owner Phone [phone]
Number
New Owner Email [e-mail]
Additional More information about the basis of this request, if needed.
Explanation
Supporting Upload Supporting Documentation if applicable.
Documentation LOAMR Prop Dist Ctr at Odessa Dr 10-5-22 updated
100.84KB
scan.pdf
Must be PDF format
Project Close-out Information:
Erosion Control Plan
Close-out Date
Erosion Control Plan Must be PDF format
Close-out
Documentation
North Carolina General Statute 143-215.613 (1) provides that:
Any person who knowingly makes any false statement, representation, or certification in any application, record, report, plan, or other document
filed or required to be maintained under this Article or a rule implementing this Article; or who knowingly makes a false statement of a material
fact in a rulemaking proceeding or contested case under this Article; or who falsifies, tampers with, or knowingly renders inaccurate any recording
or monitoring device or method required to be operated or maintained under this Article or rules of the Commission implementing this Article shall
be guilty of a Class 2 misdemeanor which may include a fine not to exceed ten thousand dollars ($10,000).
* I, as an authorized representative, hereby request rescission of coverage under the
NPDES Stormwater Permit for the subject facility. I am familiar with the information
contained in this request and to the best of my knowledge and belief such information
is true, complete and accurate.
*This form must be signed by a responsible corporate officer that owns or operates the construction activity, such as a
president, secretary, treasurer, or vice president, or a manager that is authorized in accordance with Part IV, Section B,
Item (6) of the NCGO10000 General Permit. For more information on signatory requirements, see Part IV, Section B, Item
(6) of that permit.
Signature
Type Name* Kathy Godley
Title * Manager
Organization* ITAC 469, INC
Date * 10/18/2022
Email for [e-mail]
Confirmation *
Contact Telephone* 704-577-9021

NOT Certification NOT 2022-10-12.pdf
Form Must be PDF Format
282.2KB
Is this COC Already Ensure this COC has not been rescinded since submittal!
Rescinded?
Additional Email CC'd on Notification Emails
(Optional) [e-mail]
Original Permittee CC'd on Notification Emails
Email [e-mail]
Original Site Contact CC'd on Notificaiton Emails
Email [e-mail]