New Submission

Certificate of Coverage (COC) No.*

Enter the Certificate of Coverage Number (Use capital letters)

Initial Permit Fee Status

(N/A prior to Oct 2020)

Initial Payment Received

(N/A prior to Oct 2020)

2020 Annual Fee Status

May be blank if N/A

2021 Annual Fee Status

May be blank if N/A

2022 Annual Fee Status

May be blank if N/A

2023 Annual Fee Status

May be blank if N/A

2024 Annual Fee Status

May be blank if N/A

2025 Annual Fee Status

May be blank if N/A

Information associated with this permit:

Project Name

Address

Street Address

City

State

County

Latitude

Longitude

Permittee Listed

Legally Responsible Individual

First Name

Last Name

NC Reference No.

E&SC Plan ID

Original NOI Tracking No.*

Date COC Issued*

Prior Rescission Date

This field will populate only if COC has already been rescinded.

DO NOT PROCEED with this form. This Certificate of Coverage has already been rescinded.

*

Unable to submit at this time

There are unpaid annual fees for this permit that must be resolved before submitting a Modification request. To pay outastanding invoices, please go to: deq.nc.gov/sw-epayments
(Please be aware that fees paid electronically will be applied the following business day.)

*

Unable to submit because of unpaid annual fees

Modification Information:

Reason for Modification*

Closed-Out Lots/Outparcels in E&SC PlanAdditional Lots/Outparcels Approved - E&SC RevisedOther Revision(s) to E&SC PlanLegally Responsible Individual and/or Site Contact Has ChangedMultiple Reasons (List Below)Other (Describe Below)

*

Do not submit this Modification form. Please use our new form (link below) to update permit contacts.

You can review permit contact information and enter updates with our new NCG01 Contact Update Request Form!

Reason for Modification Supporting Doc Name

This field is hidden until Review Step

Additional Description/Explanation*

More information (e.g., if lots are being added, please include specific lot numbers.)

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).

Supporting Documentation*

Upload Supporting Documentation (Revised E&SC Approval, Close-Out Doc, etc.)

Drop files here

Must be PDF format

Is this project funded with ARPA (American Rescue Plan Act) grant funds?*

This pertains to funding distributed by the N.C. Division of Water Infrastructure (DWI) only.

NoYes

ARPA Project Number*

Project number assigned by N.C. DWI (e.g., SRP-D-ARP-0090)

Is this project funded with N.C. Session Law 2023-134 Section 12.2 Earmark funds?*

NoYes

S.L. 2023-134 Project Number*

Project number assigned by N.C. DWI (e.g., SRP-D-134-0102)

North Carolina General Statute 143-215.6B (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 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 IndividualAuthorized 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 NCG010000 General Permit. For more information on signatory requirements, see Part IV, Section B, Item (6) of that permit.

Reminder: This Modification request must be submitted by the Permittee or someone within the Permittee organization who is authorized to do so.

Signature*

Type Name*

Title*

Organization*

Date*

Date will be captured on form submission

Email Address*

Email for confirmation

Telephone Number*

Contact number if we need to reach you

Note: Original permittee and site contact are copied on modification correspondence.

Additional Email (Optional)

Additional email for confirmation

Original Permittee Email

Original Site Contact Email

MODIFICATION FORM - NPDES Stormwater Permit for Construction Activities NCG010000 or NCG250000