NCC203963_NOT Signed Certification_20220920

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(COC) will be rescinded.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 NCC203963
Coverage (COC) No.* Enter the Certificate of Coverage Number (Use capital letters)
Information associated with this permit:
Project Name South Mebane Elementary Addition & Renovation
Address 600 S Third Street, Mebane, NC
County Alamance
Latitude 36.0895
Longitude-79.2758
Permittee Listed Alamance-Burlington School System
Legally Responsible Jimmy Russell
Individual
E&SC Plan ID ALAMA-2020-032
Original NOI Tracking 31090
No. *
Date COC.Issued* 09/11/2020
Prior Rescission Date This field will populate only if COC has already been rescinded.
Reason for Rescission/Termination Request:
Reason for t:) 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
For Project Close-out, you must provide documentation below. Please note, a Certificate of Occupancy
is not sufficient close-out documentation. You must provide a final inspection report or correspondence
from the authority that approved the Erosion and Sediment Control (E&SC) Plan.
Erosion Control Plan 9/1912022
Close-out Date*

Erosion Control Plan 9-13-2022 Closure Inspection Report ALAMA-2020-
Close-out 032 South Mebane Elementary Addition & 83KB
Documentation*
Renovation.pdf
Must be PDF format
North Carolina General Statute 143-215.6E (i) 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 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.
Important: The person who electronically signs this Certification must be the same person who signs the paper NOT
Certification Form (uploaded below). If that person is signing on behalf of the Permittee, that individual must be an
authorized responsible person within the same organization as the Permittee.
*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*
C, !i/Yf11,1110
Type Name* Jimmy Russell
Title* Project Manager
Organization* Alamance Burlington School System
Date* 09/20/2022
Email for [e-mail]
Confirmation*
Contact Telephone* 336-263-6184
YOU MUST MAIL THE ORIGINAL SIGNED NOT CERTIFICATION FORM (click on this link) to The Stormwater
Program at the address on the form for the application to fulfill federal requirements. You must also upload a copy of that
completed below:
NOT Certification 9-13-2022 Closure Inspection Report ALAMA-2020-
Form* 032 South Mebane Elementary Addition & 83KB
Renovation.pdf
Must be PDF Format
Additional Email
(Optional)

North Carolina Department of Environmental Quality
Land Resources: 450 W. Hanes Mill Road, Suite 300, Winston-Salem, NC 27105
[phone]
County: Alamance Project: South Mebane Elementary Addition & Renovation River basin: Cape Fear
Person financially responsible: Alamance Burlington School System Project #: ALAMA-2020-032
Address: 1712 Vaughn Rd., Burlington, NC 27217
1. Project Location: S. Third St., Mebane
Pictures: No
2. Weather and soil conditions: 80's, Clear, Workable Initial inspection: No
3. Is site currently under notice of violation? No
4. Is the site in compliance with S.P.C.A. and rules? Yes If no, check violations below:
5. Violations:
6. Is the site in compliance with NPDES Permit NCG010000 Construction Stormwater requirements? Yes
Describe:
7. Has sedimentation damage occurred since last inspection? No If Yes, where? (check all that apply)
Degree of damage:
8. Contact made with (name):
Inspection report: Sent Report
9. Corrective action needed:
Title:
Date given/sent: September 19, 2022
10. Comments: Permanent ground cover sufficient to restrain erosion has been established. No additional
self -monitoring or self -inspections are required. Project is in compliance and released under
the SPCA. Termination of coverage under the NPDES General Stormwater Permit for
Construction Activities (NCGO1) must be requested by the permittee via a Notice of
Termination (NOT). The NOT is available at:
https:Hedocs.deq.nc.gov/Forms/NCGOI-Termination. Please note that this correspondence
must be uploaded as part of completing the NOT process.
Reported by: Kimberly Turney Others present:
Date of inspection: September 13, 2022 Time arriving on site: 9:00 AM Time leaving site: 9:30 AM
cc: