NCC201875_Modification Review_20200818

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 8/18/2020 1:04:18 PM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany 8/18/2020 4:51:35 PM (Construction COC ADD TO FILE Review- NCC201875)
• The task was assigned to Georgoulias, Bethany. The due date is: August 21, 2020 5:00 PM
8/18/2020 1:04 PM

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NORTH CAPOLINA
EnYlrenmemf& Qualay
Certificate of NCC201875
Coverage (COC) Enter the Certificate of Coverage Ninber (Use capital letters)
No.*
Information associated with this permit
Project Name
Albemarle Beach Solar Farm - Phase B
Address
Cross Rd., Roper, NC
County
Washington
Latitude
35.9132
Longitude
-76.6271
Permittee Listed
Albemarle Beach Solar, LLC
Legally Responsible
Kenny Habul
Individual
NC Reference No.
NCG01-2020-1875
E&SC Plan ID
Washi-2020-006
Original NOI
25248
Tracking No.*
Date COC Issued*
05/11/2020
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This field will populate only if CCChas already been rescinded.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 Mire information if necessary
Explanation Addition to Limits of Disturbance
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 Docurrentation (%vised IRSCApproval, (lose -Cut Doc, etc.)
Documentation Washi-2020-006 Revision Albemarle Beach Solar
765.05KB
Farm - Phase B - 08172020 (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* Kenny Habul
Title * Manager
Organization* Albemarle Beach Solar, LLC
Date * 08/18/2020
Email Address* [e-mail]
En -ail for confin-ration
Telephone Number* 704-662-0375
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 08/18/2020
Rescinded Since
Submitted?

Request Date 20200818
Formatted
Review Date 20200818
Formatted