NCC204124_Modification Review_20201020

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 10/19/2020 8:11:16 AM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany 10/20/2020 7:27:45 AM (Construction COC ADD TO FILE Review- NCC204124)
• The task was assigned to Georgoulias, Bethany. The due date is: October 22, 2020 5:00 PM
10/19/2020 8:11 AM

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NORTH CAPOLINA
EnYlrenmemf& Qualay
Certificate of
NCC204124
Coverage (COC)
Enter the Certificate of Coverage Ninber (Use capital letters)
No.*
Information associated
with this permit:
Project Name
Lewisville Community Center
Address
7632 Warren Park Drive, Lewisville, NC
County
Forsyth
Latitude
36.0890
Longitude
-80.4140
Permittee Listed
Fairwood Construction LLC
Legally Responsible
Bill Heard
Individual
NC Reference No.
NCG01-2020-4124
E&SC Plan ID
FORSY-2021-001
Original NOI
31496
Tracking No.*
Date COC Issued*
09/22/2020
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This field will populate only if CCChas already been rescinded.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 Addition of clean water diversion ditch and bio cell pond.
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 NCDEQ Revised.pdf 189.38KB
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
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
1-0
Type Name* Bill Heard
Title * Owner
Organization* Fairwood Construction LLC
Date * 10/19/2020
Email Address* [e-mail]
Errail for confirmation
Telephone Number* 336-782-0176
Contact nun ber 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 10/20/2020
Rescinded Since
Submitted?

Request Date 20201019
Formatted
Review Date 20201020
Formatted