NCC191667_Modification Review_20191114

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 11/13/2019 3:06:48 PM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany 11/14/2019 11:01:11 AM (Construction COC ADD TO FILE Review -
NCC191667)
• The task was assigned to Georgoulias, Bethany. The due date is: November 18, 2019 5:00 PM
11/13/2019 3:06 PM

Y. ,
NORTH CAPCLINA
Emlremmentel Quality
Certificate of NCC191667
Coverage (COC) Enter the Certificate of Coverage N nber (Use capital letters)
No.*
Information associated with this permit
Project Name
Dollar General Ernul
Address
5615 N US Hwy 17, Vanceboro, NC
County
Craven
Latitude
35.2497
Longitude
-77.0894
Permittee Listed
Glandon Forest Equity
Legally Responsible
George Barnes
Individual
NC Reference No.
NCG01-2019-1667
E&SC Plan ID
Crave-2020-002
Original NOI
15420
Tracking No.*
Date COC Issued*
08/30/2019
Prior Rescission
This field will populate only ff CCChas already been rescinded.
Date
Modification Information:
Reason for f Closed -Out Lots/Outparcels in E&SC Plan
Modification* r Additional Lots/Outparcels Approved - E&SC Revised
r Other Revision(s) to E&SC Plan
r Multiple Reasons (List)
Addional ivbre infornation if necessary
Explanation Added .3 Acres Approved
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 Upload Supporting Docurrentation (%vised IRSCApproval, (lose -Out Doc, etc.)
Documentation Crave-2020-002 Dollar General - Ernul - 11062019
(REV).pdf 1.16MB
Mist be FDFforrrat
North Carolina General Statute 143-215.6113 (i) 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 Artide 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 device or method required to be operated or maintained under this Artide or rules of the
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 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.
'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
pt paw',
Type Name* George Barnes
Title * member/manager
Organization* Glandon Forest Equity
Date * 11 /13/2019
Email Address* [e-mail]
Bmil for Confirrration
Telephone Number* 919-459-2601
Contact N,inber if we need to reach you
Date Formatted 20191113