NCC190633_Notice of Termination_20210926

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 9/26/2021 7:45:18 AM (NOT Submittal)
Approve by Morman, Alaina 9/27/2021 4:52:15 PM (NOT Request Review- NCC190633)
• The task was assigned to Morman, Alaina. The due date is: September 30, 2021 5:00 PM
9/26/2021 7:45 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC190633
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status PAID
2021 Annual Fee Status PAST DUE
ivby be blank (if not yet billed).
This permittee owes a fee that is PAST DUE and has a pending NOD or NOV. Do not approve this NOT request
until payment is resolved. If this NOT request is acceptable, payment may be waived if applicable, but that action must
be completed first (at the NOD or NOV Review step) to ensure records are routed to the correct folder in the
repository.
However, you can reject the NOT now if it is not acceptable.
Information associated with this permit:
Project Name
Willow Oak Montessori School
Address
1476 Andrews Store Road, Pittsboro, NC
County
Chatham
Latitude
35.8200
Longitude
-79.1220
Permittee Listed
Willow Oak Montessori Charter School, Inc.
Legally Responsible
Brystana Kaufman
Individual
NC Reference No.
NCG01-2019-0633
E&SC Plan ID
2019-02067
Original NOI
12429
Tracking No.
Date COC Issued
6/17/2019
Prior Rescission
Cate populates only if COCwas already rescinded at tirre of submittal.
Date
Reason for Rescission/Termination Request:

Reason for r Project Closed -Out
Termination of r Sale (Another Owner/Operator obtained a newCOC)
Coverage * r Mistake or Invalid Coverage
f Other
Additional
Mxe information about the basis of this request, if needed.
Explanation
Brystana Kaufman is no longer President of
the Board of Directors of Willow Oak
Montessori Charter School, Inc. Charlene
Cody is the current President and Judy
Malloy the current Vice President. Ms. Malloy
is signing as the Legally Responsible
Individual.
Supporting
Upload Supporting Docurrentation if applicable.
Documentation
Mist bePIDFforrat
Project Close-out Information:
Final Close-out 9/15/2021
Inspection Approval
Project Close-out CERTIFICATE OF COMPLETION.pdf 88.62KB
Approval Mist be RYformat
Documentation
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 Artcle; 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 Artcle shall be guiltyofa Class 2 misdemeanor which mayinclude a fine not to exceed ten thousand
dollars ($10,000).
rJ 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* Judy Malloy
Title * Vice President
Organization * Willow Oak Montessori Charter School, Inc.
Date * 09/26/2021
Email for [e-mail]
Confirmation *

Contact Telephone* [phone]
NOT Certification 20210923 NCDEQ NCG01 NOT Cert Form
Form signed_20210923_0001.pdf
Mist be FDF Fornat
Is this COC Already Ensure this QDChas not been rescinded since subrrittal!
Rescinded?
Additional Email 0Cd on Notification Errails
(Optional) [e-mail]
Original Permittee 0Cd onNotification En -ails
Email [e-mail]
Original Site Contact 0Cd on Notificaiton Errails
Email [e-mail]
638KB