NCC201718_Modification Review_20201105

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 11/5/2020 10:06:50 AM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany 11/5/2020 11:04:49 AM (Construction COC ADD TO FILE Review- NCC201718)
• The task was assigned to Georgoulias, Bethany. The due date is: November 10, 2020 5:00 PM
11/5/2020 10:07 AM

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NORTH CAPOLINA
EnYlrenmemf& Qualay
Certificate of NCC201718
Coverage (COC) Enter the Certificate of Coverage N nber (use capital letters)
No.*
Information associated with this permit
Project Name
Covington Phase 2A Subdivision
Address
0 Northampton Dr, Winston-Salem, NC
County
Forsyth
Latitude
36.1430
Longitude
-80.1980
Permittee Listed
Carrolland Corporation
Legally Responsible
AI Leonard
Individual
NC Reference No.
NCG01-2020-1718
E&SC Plan ID
EN1900169
Original NOI
24748
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This field will populate only if CCChas already been rescinded.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 Wre inforrration if necessary
Explanation Stockpile area added for excess soil.
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 -Out Doc, etc.)
Documentation City of WS Email Approval.pdf 862.96KB
Mast be FDFformat
North Carolina General Statute 143-215.66 (1) 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 Artide; 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).
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
Type Name* Al Leonard
Title * Vice President
Organization* Carrolland Corporation
Date * 11 /05/2020
Email Address* [e-mail]
Errail for confirrration
Telephone Number* 3362748531
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 11/05/2020
Rescinded Since
Submitted?

Request Date 20201105
Formatted
Review Date 20201105
Formatted