NCC202513_Modification Review_20201222

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 12/22/2020 10:23:58 AM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany 12/22/2020 3:11:03 PM (Construction COC ADD TO FILE Review- NCC202513)
• The task was assigned to Georgoulias, Bethany. The due date is: December 25, 2020 5:00 PM
12/22/2020 10:24 AM

Y. ,
NORTH CAPOLINA
EnYlrenmemf& Qnalay
Certificate of
NCC202513
Coverage (COC)
Enter the Certificate of Coverage Ninber (Use capital letters)
No.*
Information associated
with this permit:
Project Name
Taking Time
Address
10401 Royster Road, Navassa, NC
County
Brunswick
Latitude
34.2700
Longitude
-78.0100
Permittee Listed
Taking Time LLC
Legally Responsible
Jamie Tatum
Individual
NC Reference No.
NCG01-2020-2513
E&SC Plan ID
BRUNS-2020-066
Original NOI
26972
Tracking No.*
Date COC Issued*
06/16/2020
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This field will populate only if CCChas already been rescinded.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 and/or Site Contact Has Changed
f Multiple Reasons (List)
Addional IVbre information if needed (e.g., new Site Contact details can be included here)
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 E&SCApproval, (lose -Cut Doc, etc.)
Documentation BRUNS-2020-066 Approval Revised 12-14-2020.pdf 287.52KB
Mast be FDFfon-rat
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 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 e)ceed ten thousand
dollars ($10,000).
rJ 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* Jamie Tatum
Title * Member Managing
Organization* Tatum Insulation III
Date * 12/22/2020
Email Address* [e-mail]
Errail for confirmation
Telephone Number* 9103712006
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 12/22/2020
Rescinded Since
Submitted?

Request Date 20201222
Formatted
Review Date 20201222
Formatted