NCC190493_Notice of Termination_20200513

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 5/13/2020 10:47:57 AM (NOT Submittal)
Approve by Georgoulias, Bethany 5/13/2020 1:09:56 PM (NOT Request Review- NCC190493)
• The task was assigned to Georgoulias, Bethany. The due date is: May 18, 2020 5:00 PM
5/13/2020 10:48 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC190493
Coverage (COC)
Enter the Certificate of Coverage Nmber
No.*
Information associated
with this permit:
Project Name
Stovall -Shaw Elementary
Address
7696 US 15, Stovall, NC
County
Granville
Latitude
36.4386
Longitude
-78.5772
Permittee Listed
Granville County Board of Education
Legally Responsible
Stan Winborne
Individual
NC Reference No.
NCG01-2019-0493
E&SC Plan ID
GRANV-2019-013
Original NOI
11772
Tracking No.
Date COC Issued
6/5/2019
Prior Rescission
Cate populates only if OOCwas already rescinded at tirre of subaittal.
Date
Reason for Rescission/Termination Request:
Reason for F Project Closed -Out
Termination of r Sale (Another Owner/Operator will apply for a new COC)
Coverage * O Mistake or Invalid Coverage
r Other
Addional We inforrration about the basis of this request, if needed.
Explanation
Supporting Upload Supporting Docurrentation if applicable.
Documentation Mist beFDFforrrat
Project Close-out Information:
Final Close-out 5/5/2020
Inspection Approval

Project Close-out 19-101 GRANV-2019-013_20200507_lnspRpt -
Approval 174.55KB
CLOSEOUT.pdf
Documentation
Mist be FL7Fforrrat
North Carolina General Statute 143-215.66 (1) provides that:
Anyperson who knowinglymakes any false statement, representation, or certification in anyapplication, record, report, plan, or other
documentfiled 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 underthis Article; or who falsifies, tampers with, or knowingly renders
inaccurate any recording or monitoring deice or method required to be operated or maintained under this Article or rules ofthe
Commission implementing this Article shall be guiltyofa Class 2 misdemeanor which mayinclude a fine not to exceed ten thousand
dollars ($10,000).
17 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 NCG010000 General Permit. For more information on signatory requirements, see Part IV, Section B,
Item (6) of that permit.
Signature
Type Name* Stan Winborne
Title * Assistant Superintendent of Operations
Organization* Granville County Public Schools
Date * 05/13/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 919-693-4613
NOT Certification 19-101 NCG01-eNOT-Certification-Form-20190508-
Form 1.62MB
DEMLR-SW-SIGNED.pdf
Wst be Ft7F Fornat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Original Permittee CCd on Wification BTails
Email [e-mail]
Original Site Contact CCd on Kbtificaiton Bmils
Email [e-mail]