NCC192170_Modification Review_20201020

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 10/19/2020 10:31:39 AM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany 10/20/2020 7:28:51 AM (Construction COC ADD TO FILE Review- NCC192170)
• The task was assigned to Georgoulias, Bethany. The due date is: October 22, 2020 5:00 PM
10/19/2020 10:31 AM

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NORTH CAPOLINA
EnYlrenmemf& Qnalay
Certificate of NCC192170
Coverage (COC) Enter the Certificate of Coverage Ninber (Use capital letters)
No.*
Information associated with this permit
Project Name
Fire Flow Improvements and Water Main Replacement Phase 3
Address
Madison St., Jackson St., Hamilton St. Thanos Dr., 10th St, Roanoke Rapids, NC
County
Halifax
Latitude
36.4647
Longitude
-77.6531
Permittee Listed
Roanoke Rapids Sanitary District
Legally Responsible
Dan Brown
Individual
NC Reference No.
NCG01-2019-2170
E&SC Plan ID
HALIF-2020-001
Original NOI
16643
Tracking No.*
Date COC Issued*
10/03/2019
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This field will populate only if COChas already been rescinded.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 * F Additional Lots/Outparcels Approved - E&SC Revised
r 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 ERSC Approval, (lose -Out Doc, etc.)
Documentation HALIF-2020-001_20201016_LOA Revised.pdf 265.87KB
Mast be FDFformat
North Carolina General Statute 143-215.66 (1) provides that:
Anyperson who knowinglymakes anyfalse 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 knowinglymakes a false statement
of a material fact in a rulemaking proceeding or contested case underthis Article; orwho falsifies, tampers with, or knowinglyrenders
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 notto 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
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
A. P" p vjm
Type Name* R. Danieley Brown, P.E.
Title * Chief Executive Officer
Organization* Roanoke Rapids Sanitary District
Date * 10/19/2020
Email Address* [e-mail]
Errail for confirmation
Telephone Number* 252-537-9137
Contact nun ber 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 confirmation
Original Permittee [e-mail]
Email
Original Site Contact [e-mail]
Email
Review Date 10/20/2020
Rescinded Since
Submitted?

Request Date 20201019
Formatted
Review Date 20201020
Formatted