NCC202092_Modification Review_20200814

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 8/13/2020 1:42:07 PM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany 8/14/2020 2:35:38 PM (Construction COC ADD TO FILE Review- NCC202092)
• The task was assigned to Georgoulias, Bethany. The due date is: August 18, 2020 5:00 PM
8/13/2020 1:42 PM

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NORTH CAPOLINA
EnYlrenmemf& Qnalay
Certificate of
NCC202092
Coverage (COC)
Enter the Certificate of Coverage Ninber (Use capital letters)
No.*
Information associated
with this permit:
Project Name
Garner Plaza SC, LLC
Address
3210 Sanderford Road, Garner, NC
County
Wake
Latitude
35.7351
Longitude
-78.6071
Permittee Listed
Jesucristo Fuente De Amor Y Vida
Legally Responsible
Robert Knowles
Individual
NC Reference No.
NCG01-2020-2092
E&SC Plan ID
SEC-032576-2020
Original NOI
25667
Tracking No.*
Date COC Issued*
05/19/2020
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This field will populate only if CCChas already been rescinded.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 * r Additional Lots/Outparcels Approved - E&SC Revised
F Other Revision(s) to E&SC Plan
r Legally Responsible Individual Has Changed
f Multiple Reasons (List)
Addional IVbre information if necessary
Explanation
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 E&SCApproval, (lose -Cut Doc, etc.)
Documentation SEC-032576-2020_Revision 1_Approval-
S&EConstruction Plan ReviewChecklist-V.2 WM 7- 293.09KB
22-20.pdf
Mast be FDFformat
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 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 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
Type Name * Robert Knowles
Title * Member
Organization* Jesucristo Fuente De Amor Y Vida
Date * 08/13/2020
Email Address* [e-mail]
Errail for confirmation
Telephone Number* 9192800141
Contact number if we need to reach you
Note: Original permittee and site contact are copied on modification correspondence.
Additional Email Additional email for confirmation
(Optional)
Original Permittee [e-mail]
Email
Original Site Contact [e-mail]
Email
Review Date 08/14/2020
Rescinded Since
Submitted?

Request Date 20200813
Formatted
Review Date 20200814
Formatted