NCC191652_Modification Review_20200623

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 6/22/2020 2:36:54 PM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany 6/23/2020 12:22:06 PM (Construction COC ADD TO FILE Review- NCC191652)
• The task was assigned to Georgoulias, Bethany. The due date is: June 25, 2020 5:00 PM
6/22/2020 2:37 PM

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NORTH CAPOLINA
EnYlrenmemf& Qualay
Certificate of NCC191652
Coverage (COC) Enter the Certificate of Coverage Ninber (Use capital letters)
No.*
Information associated with this permit
Project Name
City Contract City of Hickory Riverwalk
Address
2035 12th Street Drive NW, Hickory, NC
County
Burke
Latitude
35.7654
Longitude
-81.3686
Permittee Listed
City of Hickory
Legally Responsible
Warren Wood
Individual
NC Reference No.
NCG01-2019-1652
E&SC Plan ID
BURKE-2019-017
Original NOI
15360
Tracking No.*
Date COC Issued*
09/03/2019
Prior Rescission
This field will populate only if COChas already been rescinded.
Date
Modification Information:
Reason for r Closed -Out Lots/Outparcels in E&SC Plan
Modification * r Additional Lots/Outparcels Approved - E&SC Revised
F Other Revision(s) to E&SC Plan
r Legally Responsible Individual Has Changed
r Multiple Reasons (List)
Addional We inforrration if necessary
Explanation City Riverwalk project has been revised for value engineering.
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 (%vised ERSC Approval, (lose -Out Doc, etc.)
Documentation LOAwPR revision 6-10-2020.docxpdf 1.01MB
Mast be FDFfon-rat
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 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 guiltyofa Class 2 misdemeanor which mayinclude a fine not to e)ceed ten thousand
dollars ($10,000).
rJ 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:* r The Legally Responsible Individual
r 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 NCG010000 General Permit. For more information on signatory requirements, see Part IV, Section B,
Item (6) of that permit.
Signature
w't nw
Type Name* Warren Wood
Title * City Manager
Organization * City of Hickory
Date * 06/22/2020
Email Address* [e-mail]
Errail for confirrration
Telephone Number* 828-323-7412
Contact nurrber if we need to reach you
Note: Original permittee and site contact are copied on modification correspondence.
Additional Email [e-mail]
(Optional) Additional errail for confirrration
Original Permittee [e-mail]
Email
Original Site Contact [e-mail]
Email
Review Date 06/23/2020
Rescinded Since
Submitted?

Request Date 20200622
Formatted
Review Date 20200623
Formatted