NCC201820_Modification Review_20200911

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 9/11/2020 10:11:02 AM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany 9/11/2020 10:13:37 AM (Construction COC ADD TO FILE Review- NCC201820)
• The task was assigned to Georgoulias, Bethany. The due date is: September 16, 2020 5:00 PM
9/11/2020 10:11 AM

Y. ,
NORTH CAPOLINA
EnYlrenmemf& Qualay
Certificate of NCC201820
Coverage (COC) Enter the Certificate of Coverage N nber (Use capital letters)
No.*
Information associated with this permit:
Project Name Beach Bum
Address NC-179, Ocean Isle Beach, NC
County Brunswick
Latitude 33.9010
Longitude-78.4520
Permittee Listed Beach Bum, LLC.
Legally Responsible Tom Athey
Individual
NC Reference No. NCG01-2020-1820
E&SC Plan ID
Original NOI
Tracking No.
BRUNS-2020-061
24949
Date COC Issued* 05/11/2020
Prior Rescission This field will populate only if CCChas already been rescinded.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
r Multiple Reasons (List)
Addional Mire inforrration if necessary
Explanation The plan was revised to due to a change in stormwater pond 1 (Sediment Basin 1).
The change caused some buildings/roadway to be trimmed back to accommodate
the revised pond 1. No additional limits of disturbance were added to the project.
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 -Cut Doc, etc.)
Documentation BRUNS-2020-061 Approval Revised 9-3-2020.pdf 286.46KB
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 exceed ten thousand
dollars ($10,000).
17 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 NCG010000 General Permit. For more information on signatory requirements, see Part IV, Section B,
Item (6) of that permit.
Signature
0&157
Type Name* Tom Athey
Title * Member
Organization* Beach Bum, LLC.
Date * 09/11 /2020
Email Address* [e-mail]
Errail for confirmation
Telephone Number* 704-614-1262
Contact nurrber 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 09/11/2020
Rescinded Since
Submitted?

Request Date 20200911
Formatted
Review Date 20200911
Formatted