NCC201713_Modification Review_20200603

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 6/2/2020 1:47:26 PM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany 6/3/2020 7:42:21 AM (Construction COC ADD TO FILE Review- NCC201713)
• The task was assigned to Georgoulias, Bethany. The due date is: June 5, 2020 5:00 PM
6/2/2020 1:47 PM

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NORTH CAPOLINA
EnYlrenmemf& Qualay
Certificate of NCC201713
Coverage (COC) Enter the Certificate of Coverage Ninber (Use capital letters)
No.*
Information associated with this permit:
Project Name McClenny Acres Mitigation Site
Address Old Smithfield Road - Rear, Fork Township (Rosewood), NC
County Wayne
Latitude 35.3928
Longitude-78.0595
Permittee Listed Wildlands Engineering
Legally Responsible John Hutton
Individual
NC Reference No. NCG01-2020-1713
E&SC Plan ID Wayne-2020-014
Original NOI 24675
Tracking No.*
Date COC Issued* 04/28/2020
Prior Rescission This field will populate only if CCChas already been rescinded.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 Has Changed
r Multiple Reasons (List)
Addional Nbre information if necessary
Explanation Limits of disturbance expanded to additional areas on the same property.
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 Documentation (%vised IRSCApproval, (lose -Out Doc, etc.)
Documentation Wayne-2020-014 McClenny Acres - 05272020
833.2KB
(REV).pdf
Wst be FDFfornat
North Carolina General Statute 143-215.6113 (i) 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 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:* r The Legally Responsible Individual
f 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* John Hutton
Title * Vice President
Organization* Wildlands Engineering
Date * 06/02/2020
Email Address* [e-mail]
En -ail for confin-ration
Telephone Number* 9197238203
Contact nunber if we need to reach you
Note: Original permittee and site contact are copied on modification correspondence.
Additional Email [e-mail]
(Optional) Additional en -ail for confin-ation
Original Permittee [e-mail]
Email
Original Site Contact [e-mail]
Email
Review Date 06/03/2020
Rescinded Since
Submitted?

Request Date 20200602
Formatted
Review Date 20200603
Formatted