NCC202870_Modification Review LOT 61_20200720

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 7/20/2020 8:19:20 AM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany 7/20/2020 2:43:41 PM (Construction COC ADD TO FILE Review- NCC202870)
• The task was assigned to Georgoulias, Bethany. The due date is: July 23, 2020 5:00 PM
7/20/2020 8:19 AM

Y . Ta4M1
NORTH CAPOLINA
EnYlrenmemf& Qualay
Certificate of NCC202870
Coverage (COC) Enter the Certificate of Coverage N nber (use capital letters)
No.*
Information associated with this permit:
Project Name Willoughby lot 15
Address 3022 Freeman Farm Way, Rolesville, NC
County Wake
Latitude 35.9304
Longitude-78.4711
Permittee Listed The Drees Company
Legally Responsible Jerry Dean
Individual
NC Reference No. NCG01-2020-2870
E&SC Plan ID
Original NOI
Tracking No.
SEC-039552-2020
27811
Date COC Issued* 07/09/2020
Prior Rescission This field will populate only if CCChas already been rescinded.
Date
Modification Information:
Reason for r Closed -Out Lots/Outparcels in E&SC Plan
Modification * F Additional Lots/Outparcels Approved - E&SC Revised
r Other Revision(s) to E&SC Plan
r Legally Responsible Individual Has Changed
r Multiple Reasons (List)
Addional We inforrration if necessary
Explanation Please note that if you already have a Certificate of Coverage in this subdivision,
you may utilize the NCDEQ NCG01 Modification Form to add additional lots and
approvals to it. THIS IS THE NOTE ON THE APPROVAL LETTER FROM THE
COUNTY, LET ME KNOW IF I AM DOING THIS CORRECTLY
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 Ibcurrentation (Pevised E&SCApproval, nose -Out Doc, etc.)
Documentation WBY 61 SEC-040155-2020_Approval-
S&EConstruction Plan ReviewChecklist-V.2 WM 7- 272.02KB
18-20.pdf
Mist be FDFfornat
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).
� 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
f 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* Jerry Dean
Title * Division President
Organization* The Drees Company
Date * 07/20/2020
Email Address* [e-mail]
En -ail for confirnation
Telephone Number* 9198449288
Contact nunber if we need to reach you
Note: Original permittee and site contact are copied on modification correspondence.
Additional Email Additional enailfor confirrration
(Optional)
Original Permittee [e-mail]
Email
Original Site Contact [e-mail]
Email
Review Date 07/20/2020

Rescinded Since
Submitted?
Request Date 20200720
Formatted
Review Date 20200720
Formatted