NCC200829_Modification Review (LEG RESP CHANGE)_20210303

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 3/1/2021 4:30:50 PM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany 3/3/2021 9:12:39 AM (Construction COC ADD TO FILE Review- NCC200829)
Revisions to legally responsible person via the Contact Change form will follow.
• The task was assigned to Georgoulias, Bethany. The due date is: March 4, 2021 5:00 PM
3/1/2021 4:30 PM

Y . Ta4M1
NORTH CAPOLINA
EnYlrenmemf& Qualay
Certificate of NCC200829
Coverage (COC) Enter the Certificate of Coverage Ninber (Use capital letters)
No.*
Information associated with this permit:
Project Name Maiden Lane Phase 2 Sanitary Sewer and Water Relocation
Address Maiden Lane, Fayetteville, NC
County Cumberland
Latitude 35.0000
Longitude-79.0000
Permittee Listed Fayetteville Public Works Commision
Legally Responsible Joseph Glass
Individual
NC Reference No. NCG01-2020-0829
E&SC Plan ID
Original NOI
Tracking No.
CUMBE-2020-097
22454
Date COC Issued* 03/16/2020
Prior Rescission This field will populate only if COChas already been rescinded.
Date
Modification Information:
Reason for r Closed -Out Lots/Outparcels in E&SC Plan
Modification * a Additional Lots/Outparcels Approved - E&SC Revised
r Other Revision(s) to E&SC Plan
F Legally Responsible Individual and/or Site Contact Has Changed
r Multiple Reasons (List)
Addional Ivbre inforrration (e.g., new Site Contact details). If lots are being added, please include specific lot nunbers.
Explanation Joseph Glass has retired. Misty Manning has taken his place as Department
Manager.
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 (Fevised E&SCApproval, nose -Out Doc, etc.)
Documentation NCG01-Legal ly-Responsible-Change-Form-
1.12MB
20201205-DEMLR-SW. pdf
Mast be FDFformat
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 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 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 NCGO10000 General Permit. For more information on signatory requirements, see Part IV, Section B,
Item (6) of that permit.
Signature
Type Name* Misty M. Manning
Title * Water Resources Engineering Manager
Organization* Fayetteville Public Works Commission
Date * 03/01 /2021
Email Address* misty. [e-mail]
Errail for confirmation
Telephone Number* 910-223-4730
Contact number if we need to reach you
Note: Original permittee and site contact are copied on modification correspondence.
Additional Email [e-mail]
(Optional) Additional errail for confirmation
Original Permittee [e-mail]
Email
Original Site Contact [e-mail]
Email
Review Date 03/03/2021
Rescinded Since
Submitted?

Request Date 20210301
Formatted
Review Date 20210303
Formatted