NCC190490_Modification Review_20191028

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 10/25/2019 1:35:05 PM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany 10/28/2019 8:50:37 AM (Construction COC ADD TO FILE Review- NCC190490)
The task was assigned to Georgoulias, Bethany. The due date is: October 30, 2019 5:00 PM
10/25/2019 1:35 PM

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NORTH CAROUNA
e'vorwMienfal Quanty
Certificate of NCC190490
Coverage (COC) Enter the Certificate of Coverage Minter (Use capital letters)
No. *
Information associated with this permit
Project Name
Westchester County Day School
Address
2045 N. Old Greensboro Road, Hlgh Point, NC
County
Davidson
Latitude
35.9735
Longitude
-80.0898
Permittee Listed
Westchester County Day School
Legally Responsible
Cobb Atkinson
Individual
NC Reference No.
NCG01-2019-0490
E&SC Plan ID
DAVID-2019-022
Original NOI
11766
Tracking No.*
Date COC Issued*
06/05/2019
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This field will populate only if COChas already been rescinded.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 Revisions including removal of tennis courts, addition of phase lines, demolition
and rebuild of the Cats Den building and adjustment of fill slope away from creek.
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 Documentation (Revised E&SCApproval, dose -Out Doc, etc.)
Documentation Westchester Grading Permit_2019-10-15.pdf 11.28MB
Mist be F13F forrrat
North Carolina General Statute 143-215.613 (1) provides that:
Any person who knowingly makes any false statement, representation, or certification in anyapplication, record, report, plan, or other
documentfiled or required to be maintained underthis 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).
I7 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
bu,Omsk
Type Name*
Cobb Atkinson
Title *
Headmaster
Organization *
Westchester County Day School
Date *
10/25/2019
Email Address*
[e-mail]
Email for Confirmation
Telephone Number*
3368696685
Contact Namber if we need to reach you
Date Formatted
20191025