NCC203636_Modification Review_20210111

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 1/8/2021 2:03:05 PM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany 1/11/2021 7:19:33 AM (Construction COC ADD TO FILE Review- NCC203636)
• The task was assigned to Georgoulias, Bethany. The due date is: January 13, 2021 5:00 PM
1 /8/2021 2:03 PM

Y. ,
NORTH CAPOLINA
EnYlrenmemf& Qualay
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
Original NOI
Tracking No.
MECKL-2021-008
30141
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Prior Rescission This field will populate only if CDC has already been rescinded.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 and/or Site Contact Has Changed
r Multiple Reasons (List)
Addional Nbre information if needed (e.g., new Site Contact details can be included here)
Explanation Phases 1-4 were reviewed and approved by NCDEQ, whereas this final phase 5
attached was reviewed and approved by the City of Charlotte. This phase shows
an increase in denuded acreage for the installation of infrastructure, inlet
protection, grading, site features, etc.
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 Lbcurrentation (%vised IRSCApproval, (lose -Out Doc, etc.)
Documentation Grading Letter of Approval - Centene East Coast
91.55KB
Headquarters. pdf
Mast be R Fforrrat
North Carolina General Statute 143-215.6B (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).
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* Tobias Rafael
Title * Owner's Representative
Organization * Centene Management Company, LLC
Date * 01 /08/2021
Email Address* [e-mail]
Brail for confin-ration
Telephone Number* 3147218427
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 01/11/2021

Rescinded Since
Submitted?
Request Date 20210108
Formatted
Review Date 20210111
Formatted