NCC216683_Modification Review_20220407

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 4/6/2022 8:57:55 PM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany A 4/7/2022 1:52:34 PM (Construction COC ADD TO FILE Review - NCC216683)
The task was assigned to Georgoulias, Bethany A. The due date is: April 11, 2022 5:00 PM
4/6/2022 8:58 PM

JjAl'i
NORTH LAPOLINA
Cn iranmenfet Quality
Certificate of NCC216683
Coverage (COC) No.* Enter the Certificate of Coverage Number (Use capital letters)
Information associated with this permit:
Project Name East Clayton Community Park
Address 1774 Glen Laurel Road, Clayton, NC
County Johnston
Latitude 35.6373
Longitude-78.4152
Permittee Listed Town of Clayton
Legally Responsible Richard Cappola
Individual
NC Reference No. NCG01-2021-6683
E&SC Plan ID JOHNS-2022-027
Original NOI Tracking 74589
No. *
Date COC Issued * 12/02/2021
Prior Rescission Date This field will populate only if COC has already been rescinded.
Modification Information:
Reason for Closed -Out Lots/Outparcels in E&SC Plan
Modification* Additional Lots/Outparcels Approved - E&SC Revised
• Other Revision(s) to E&SC Plan
Legally Responsible Individual and/or Site Contact Has Changed
Multiple Reasons (List)
Addional Explanation More information (e.g., new Site Contact details). If lots are being added, please include specific lot numbers.
Construction entrance added for construction access.
You must upload supporting documentation below. Do not upload E&SC Plans unless specific plan
sheets are the only documentation with approval for revised acres of disturbance, etc. (only upload
applicable sheets).
For changes to the legally responsible individual, you must upload this form.

Supporting Upload Supporting Documentation (Revised E&SC Approval, Close -Out Doc, etc.)
Documentation Revised DEQ LOA JOHNS-2022-
136.47KB
027_20220405_.pdf
Revised DEQ COA JOHNS-2022
329.24KB
027_20220405_ECCP. pdf
Must be PDF format
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 hereby request modification to coverage under the NPDES Stormwater Permit for the
subject project site. 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.
Specify if you are:* • The Legally Responsible Individual
Authorized Responsible Person`
*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* Richard D. Cappola
Title* Interim Town Manager
Organization * Town of Clayton
Date * 04/06/2022
Email Address* [e-mail]
Email for confirmation
Telephone Number* 919-553-5002
Contact number if we need to reach you
Note: Original permittee and site contact are copied on modification correspondence.
Additional Email [e-mail]
(Optional) Additional email for confirmation
Original Permittee [e-mail]
Email
Original Site Contact [e-mail]
Email
Review Date 04/07/2022
Rescinded Since
Submitted?

Request Date 20220406
Formatted
Review Date 20220407
Formatted