NCC200455_Modification Review_20200217

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 2/10/2020 11:24:07 AM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany 2/17/2020 12:03:52 PM (Construction COC ADD TO FILE Review- NCC200455)
* No additional acreage disturbance.
• The task was assigned to Georgoulias, Bethany. The due date is: February 13, 2020 5:00 PM
2/10/2020 11:24 AM

NORTH CAPCLINA
Emlremmentel Quality
Certificate of NCC200455
Coverage (COC) Enter the Certificate of Coverage N nber (Use capital letters)
No.*
Information associated with this permit:
Project Name PNG Line 328 Relocation A
Address White Rock Road, Winston-Salem, NC
County Forsyth
Latitude 36.1785
Longitude-80.2157
Permittee Listed Piedmont Natural Gas
Legally Responsible Sanu Odugbesan
Individual
NC Reference No. NCG01-2020-0455
E&SC Plan ID
Original NOI
Tracking No.*
FORSY-2020-013
21488
Date COC Issued* 02/06/2020
Prior Rescission This field will populate only ff OOChas already been rescinded.
Date
Modification Information:
Reason for f Closed -Out Lots/Outparcels in E&SC Plan
Modification* r Additional Lots/Outparcels Approved - E&SC Revised
r Other Revision(s) to E&SC Plan
r Multiple Reasons (List)
Addional ivbre infornation if necessary
Explanation Temporary Access Road #1 has been modified to route to the west of current
approved plan through the same landowner's property (NCDOT) and result in no
additional acreage of disturbance. Additionally, this new route will minimize grading
and move further away from environmentally sensitive features. See attached map
for new Temporary Access Road #1.
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 (Fevised E&SCApproval, rose -Out Doc, etc.)
Documentation Line 328 ACCESS ROAD ROUTE MODIFICATION
2.59MB
(002).pdf
Mast be PDFforrrat
North Carolina General Statute 143-215.66 (1) provides that:
Anyperson who knowinglymakes anyfalse 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 underthis Article; orwho 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 notto e)ceed ten thousand
dollars ($10,000).
rJ 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
0�A-1141W'
Type Name* Sanu Odugbesan
Title * Project Manager
Organization* Piedmont Natural Gas
Date * 02/10/2020
Email Address* [e-mail]
Email for Confirrration
Telephone Number* 704-731-4246
Contact KUnber if we need to reach you
Date Formatted 20200210