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HomeMy WebLinkAboutNCC201608_Modification Review (LEG RESP CHANGE)_20230315Action History (UTC-05:00) Eastern Time (US & Canada) Submit by Anonymous User 3/13/2023 11:24:14 AM (ADD TO FILE Submittal) Approve by bethany.georgoulias 3/15/2023 12:45:04 PM (Construction COC ADD TO FILE Review - NCC201608) • Legally responsible person updated 3/15/2023. The task was assigned to bethany.georgoulias. The due date is: March 16, 2023 5:00 PM 3/13/2023 11:24:15 AM E Certificate of NCC201608 Coverage (COC) No.* Enter the Certificate of Coverage Number (Use capital letters) Information associated with this permit: Project Name Contract 2011-067, Alamance Church Road Improvements Address Alamance Church Road, Greensboro, NC County Guilford Latitude 36.0359 Longitude-79.7598 Permittee Listed City of Greensboro Legally Responsible John Fersner Individual NC Reference No. NCG01-2020-1608 E&SC Plan ID GUILF-2020-035 Original NOI Tracking 24596 No.* Date COC Issued* 04/29/2020 Prior Rescission Date This field will populate only if COC has already been rescinded. Modification Information: Reason for Modification* Closed -Out Lots/Outparcels in E&SC Plan Additional Lots/Outparcels Approved - E&SC Revised Other Revision(s) to E&SC Plan Legally Responsible Individual and/or Site Contact Has Changed Multiple Reasons (List) Addional Explanation More information (e.g., new Site Contact details). If lots are being added, please include specific lot numbers 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 Documentation Upload Supporting Documentation (Revised E&SC Approval, Close -Out Doc, etc.) 2011-067_NCG01_LRI_CHANGE_FORM.pdf 1.07MB Must be PDF format Is this project funded with ARPA (American Rescue Plan Act) grant funds? No Yes This question was added to the eNOl on 2/3/2023 and will not be answered in applications submitted prior to that date. North Carolina General Statute 143-215.613 (i) provides that: Any person who knowingly makes any false statement, representation, or certification in any application, record, report, plan, or other document filed 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 under this 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 guilty of a Class 2 misdemeanor which may include 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:* The Legally Responsible Individual 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 I, /✓row -L 5' lW Al '- c%005. Type Name* JASON S. GEARY, P.E. Title* CITY ENGINEER Organization* CITY OF GREENSBORO Date * 03/13/2023 Email Address* JASON.GEARY@GREENSBORO-NC.GOV Email for confirmation Telephone Number* 336-373-2302 Contact number if we need to reach you Note: Original permittee and site contact are copied on modification correspondence. Additional Email GUY. INGLE@GREENSBORO-NC.GOV (Optional) Additional email for confirmation Original Permittee John.Fersner@greensboro-nc.gov Email Original Site Contact Melinda.King@greensboro-nc.gov Email Review Date 03/15/2023 Rescinded Since Submitted?