NCC190411_Modification Review_20190905

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 9/5/2019 9:37:02 AM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany 9/5/2019 10:24:15 AM (Construction COC ADD TO FILE Review- NCC190411)
• The task was assigned to Georgoulias, Bethany. The due date is: September 10, 2019 5:00 PM
9/5/2019 9:37 AM

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NORTHCAROLINA
e'vorwMienfal Quanty
Certificate of
NCC190411
Coverage (COC)
Enter the Certificate of Coverage Minber (Use capital letters)
No. *
Information associated
with this permit:
Project Name
Lake Wheeler Creamery Cafe and Education Center
Address
100 Dairy Lane, Raleigh, NC
County
Wake
Latitude
36.0000
Longitude
-79.0000
Permittee Listed
NC State University
Legally Responsible
Mary Peloquin-Dodd
Individual
NC Reference No.
NCG01-2019-0411
E&SC Plan ID
WAKE-2019-092
Original NOI
11540
Tracking No.*
Date COC Issued*
05/31/2019
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This field will populate only if COChas already been rescinded.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
f Multiple Reasons (List)
Ad d io n al Ivbre information if necessary
Explanation Project site was expanded to include construction of a septic drain field.
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).

Supporting Upload Supporting Docurrentation (Revised E&SCApproval, (lose -Out Doc, etc.)
Documentation WAKE-2019-092 LOA20190904 revised-2.pdf
56.96KB
C-301-rev01.pdf
1.08MB
C-302-rev02.pdf
1.31 MB
C-304-rev02. pdf
781.17 KB
C-401-rev01.pdf
930.61 KB
C-402-rev01.pdf
526.57KB
C-503-rev01.pdf
654.47KB
Mist be FDF format
North Carolina General Statute 143-215.6B (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 knowinglymakes 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 guiltyofa Class 2 misdemeanor which mayinclude a fine not to exceed ten thousand
dollars ($10,000).
17 I, as an authorized representative, 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.
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* Mary Peloquin-Dodd
Title * Associate Vice Chancellor for Finance and University Treasurer
Organization* NC State University
Date * 09/05/2019
Email Address* [e-mail]
Email for Confirrration
Telephone Number* 919-515-6861
Contact Narrber if we need to reach you
Date Formatted 20190905