NCC203050_Modification Review_20200731

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 7/31/2020 10:11:49 AM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany 7/31/2020 1:53:38 PM (Construction COC ADD TO FILE Review- NCC203050)
• The task was assigned to Georgoulias, Bethany. The due date is: August 5, 2020 5:00 PM
7/31/2020 10:12 AM

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NORTH CAPOLINA
EnYlrenmemf& Qnalay
Certificate of NCC203050
Coverage (COC) Enter the Certificate of Coverage N nber (Use capital letters)
No.*
Information associated with this permit
Project Name
Chatham Park Gas Main Extension
Address
US 64/East St. and others, Pittsboro, NC
County
Chatham
Latitude
35.7251
Longitude
-79.1791
Permittee Listed
Dominion Energy of North Carolina, Inc.
Legally Responsible
Shaun Randall
Individual
NC Reference No.
NCG01-2020-3050
E&SC Plan ID
Chath-2020-014
Original NOI
28371
Tracking No.*
Date COC Issued*
07/21/2020
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This field will populate only if CCChas already been rescinded.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 * a Additional Lots/Outparcels Approved - E&SC Revised
O Other Revision(s) to E&SC Plan
r Legally Responsible Individual Has Changed
F Multiple Reasons (List)
Error in the E&SC Project ID assignment - new LOA issued
Addional IVbre information if necessary
Explanation
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 ESCApproval, (lose -Cut Doc, etc.)
Documentation CHATI-1-2021-001_20200708_COA.pdf 325.48KB
Mast be FDFfon-rat
North Carolina General Statute 143-215.66 (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 Artide; or who knowingly makes a false statement
of a material fact in a rulemaking proceeding or contested case underthis 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 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
r 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
6W C9ra"T Able 1,
Type Name* M. Shaun Randall
Title * Vice President - Gas Operations
Organization* Dominion Energy North Carolina
Date * 07/31 /2020
Email Address* [e-mail]
Errail for confirmation
Telephone Number* 704-810-3350
Contact nurrber if we need to reach you
Note: Original permittee and site contact are copied on modification correspondence.
Additional Email Additional email for confirmation
(Optional)
Original Permittee [e-mail]
Email
Original Site Contact [e-mail]
Email
Review Date 07/31/2020
Rescinded Since
Submitted?

Request Date 20200731
Formatted
Review Date 20200731
Formatted