NCC204227_Notice of Termination_20221213

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 12/13/2022 8:59:32 AM (NOT Submittal)
Approve by Clark, Paul B 12/13/2022 10:56:59 PM (NOT Request Review - NCC204227)
• The task was assigned to Clark, Paul B by round robin distribution 12/13/2022 8:59 AM
The task was assigned to DEMLR NCG01 NOT Review Team. The due date is: December 16, 2022 5:00
PM 12/13/2022 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(COC) will be rescinded.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 NCC204227
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 PAID PAID
May be blank if N/A May be blank if N/A
Information associated with this permit:
Project Name Sam's Xpress Car Wash - Fuquay Varina, NC
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
1532 North Main Street, Fuquay Varina, NC
County
Wake
Latitude
35.5947
Longitude
-78.7634
Permittee Listed
SXCW Properties II, LLC
Legally Responsible
Sami Nafisi
Individual
NC Reference No.
NCG01-2020-4227
E&SC Plan ID
SP-2018-14
Original NOI Tracking
31783
No.
Date COC Issued
9/28/2020
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Date populates only if COC was already rescinded at time of submittal.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

Additional
More information about the basis of this request, if needed.
Explanation
This NOT was originally rejected because E&SC plan id + SP-2018-14 (eNOT), but
EC-2018-16 (uploaded copy) were not the same. I spoke to Billy Holman with the
town of Fuquay Varina. He said that those are supposed to be different numbers,
SP-2018-14 is the plan ID and EC-2018-16 is the project number. I did confirm with
him that EC-2018-16 is the correct project number.
Also attached below is the consent & resolution form allowing Anthony to sign for
Sami.
I have also paid the outstanding fee due.
Supporting
Upload Supporting Documentation if applicable.
Documentation
Must be PDF format
Project Close-out
Information:
Erosion Control Plan 12/8/2022
Close-out Date
Erosion Control Plan Sam's Xpress Carwash 12.8.2022 Final.pdf 340.88KB
Close-out Consent & Resolution Limited (Permitting Docs for
Documentation 188.19KB
Anthony Warren) (with notary) - 08262021.pdf
Stormwater ePayments Receipts _ NC DEQ.pdf 149.23KB
Must be PDF format
North Carolina General Statute 143-215.6113 (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* Anthony Warren
Title* Director of Development
Organization * SXCW Properties 11, LLC
Date * 12/13/2022
Email for [e-mail]
Confirmation*
Contact Telephone* 7044336501

NOT Certification NOT certification form - Fuquay Varina.pdf
Form Must be PDF Format
297.05KB
Is this COC Already Ensure this COC has not been rescinded since submittal!
Rescinded?
Additional Email CC'd on Notification Emails
(Optional)
Original Permittee CC'd on Notification Emails
Email [e-mail]
Original Site Contact CC'd on Notificaiton Emails
Email [e-mail]