NCC191758_Modification Approval to Include Amendment_20210111

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 1/11/2021 12:26:39 PM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany 1/11/2021 1:29:26 PM (Construction COC ADD TO FILE Review- NCC191758)
p Submitter listed internal organizational area instead of permitted entity but is with Pee Dee Electric and
the same legally responsible individual.
• The task was assigned to Georgoulias, Bethany. The due date is: January 14, 2021 5:00 PM
1/11/2021 12:26 PM

Y . Ta4M1
NORTH CAPOLINA
EnYlrenmemf& Qualay
Certificate of
NCC191758
Coverage (COC)
Enter the Certificate of Coverage Ninber (Use capital letters)
No.*
Information associated
with this permit:
Project Name
Burnsville Substation
Address
Race Track Road, Polkton, NC
County
Anson
Latitude
35.1124
Longitude
-80.2444
Permittee Listed
Pee Dee Electric Membership Corporation
Legally Responsible
Anthony Eason
Individual
NC Reference No.
NCG01-2019-1758
E&SC Plan ID
ANSON-2020-001
Original NOI
15639
Tracking No.*
Date COC Issued*
09/09/2019
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This field will populate only if COChas already been rescinded.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 * a Additional Lots/Outparcels Approved - E&SC Revised
O Other Revision(s) to E&SC Plan
r Legally Responsible Individual and/or Site Contact Has Changed
F Multiple Reasons (List)
See additional explanation below
Addional MDre inforrration if needed (e.g., new Site Contact details can be included here)
Explanation This modification should include everything originally submitted for the later
NCC192121, and NCC192121 will be closed out.
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 (Pevised E&SCApproval, nose -Out Doc, etc.)
Documentation Burnsville Modification. pdf 372.37KB
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 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).
� 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* Anthony E Eason
Title * Vice President
Organization* Engineering and Operations
Date * 01 /11 /2021
Email Address* [e-mail]
En -ail for confirnation
Telephone Number* 9109978941
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 01/11/2021
Rescinded Since
Submitted?

Request Date 20210111
Formatted
Review Date 20210111
Formatted