NCC210640_Modification Review_20210324

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 3/23/2021 5:53:14 PM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany 3/24/2021 7:36:25 AM (Construction COC ADD TO FILE Review- NCC210640)
• The task was assigned to Georgoulias, Bethany. The due date is: March 26, 2021 5:00 PM
3/23/2021 5:53 PM

Y. ,
NORTH CAPOLINA
EnYlrenmemf& Qualay
Certificate of NCC210640
Coverage (COC) Enter the Certificate of Coverage Ninber (Use capital letters)
No.*
Information associated with this permit:
Project Name Troutman Industrial Park
Address 386 Murdock Rd, Troutman, NC
County Iredell
Latitude 35.7180
Longitude-80.8770
Permittee Listed Walmart Fulfillment Services, LLC
Legally Responsible Mark Goldsmith
Individual
NC Reference No. NCG01-2021-0640
E&SC Plan ID
Original NOI
Tracking No.
TRTMN-2018-085
42434
Date COC Issued* 02/03/2021
Prior Rescission This field will populate only if CCChas already been rescinded.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 and/or Site Contact Has Changed
r Multiple Reasons (List)
Addional Wre information (e.g., new Site Contact details). If lots are being added, please include specific lot nunbers.
Explanation This COC was applied for under the previously approved 3 acre modification on
1/7/20 (prior to property transfer - the old COC number was NCC191493). This
modification is to update to reflect the revision of 12.65 acres of disturbance
approved by Iredell County on 2/16/21. Coordination on this project has been
handled with Alaina Morman.
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 Docurrentation (Plevised E&SCApproval, Close -Out Doc, etc.)
Documentation LOAM Troutman Industrial 2-16-21 scan.pdf 69.81 KB
Mast be PDFformat
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).
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
IT 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* Mark S Goldsmith, CPESC, CESSWI, QSM
Title * Director EH&S Compliance
Organization * Walmart Fulfillment Service, LCC
Date * 03/23/2021
Email Address* [e-mail]
Errail for confirmation
Telephone Number* 479-360-4749
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 email for confirmation
Original Permittee [e-mail]
Email
Original Site Contact [e-mail]
Email
Review Date 03/24/2021

Rescinded Since
Submitted?
Request Date 20210323
Formatted
Review Date 20210324
Formatted