NCC203636_Modification Review_20201012

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 10/12/2020 3:05:48 PM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany 10/12/2020 3:23:55 PM (Construction COC ADD TO FILE Review- NCC203636)
• The task was assigned to Georgoulias, Bethany. The due date is: October 15, 2020 5:00 PM
10/12/2020 3:05 PM

Y. ,
NORTH CAPOLINA
EnYlrenmemf& Qnalay
Certificate of NCC203636
Coverage (COC) Enter the Certificate of Coverage N nber (Use capital letters)
No.*
Information associated with this permit
Project Name
Centene East Coast Headquarters (Express Review)
Address
2405 GOVERNOR HUNT RD, Charlotte, NC
County
Mecklenburg
Latitude
35.3276
Longitude
-80.7659
Permittee Listed
Centene Management Company, LLC
Legally Responsible
Tobias Rafael
Individual
NC Reference No.
NCG01-2020-3636
E&SC Plan ID
MECKL-2021-008
Original NOI
30141
Tracking No.*
Date COC Issued*
09/02/2020
Prior Rescission
This field will populate only if CDC has already been rescinded.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
f Multiple Reasons (List)
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 ERSC Approval, (lose -Out Doc, etc.)
Documentation Centene East Coast Headquarters (MECKL-2021-
322.06KB
008) approval w mods 2.pdf
Wst be FDFfornat
North Carolina General Statute 143-215.6113 (i) 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 Artide or a rule implementing this Article; 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 Artide 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).
� 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
0�01e'54l
Type Name* Tobias Rafael
Title * Owner's Representative
Organization * Centene Management Company, LLC
Date * 10/12/2020
Email Address* [e-mail]
B7ail for confin-ration
Telephone Number* 314.721.8427
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 10/12/2020
Rescinded Since
Submitted?

Request Date 20201012
Formatted
Review Date 20201012
Formatted