NCC201366_Modification Review_20210409

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 4/9/2021 11:15:06 AM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany 4/9/2021 4:31:33 PM (Construction COC ADD TO FILE Review- NCC201366)
• The task was assigned to Georgoulias, Bethany. The due date is: April 14, 2021 5:00 PM
4/9/2021 11:15 AM

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NORTH CAPOLINA
EnYlrenmemf& Qualay
Certificate of NCC201366
Coverage (COC) Enter the Certificate of Coverage Ninber (Use capital letters)
No.*
Information associated with this permit:
Project Name Clemmons Town Center Outparcel 1
Address Gentry Lane, Clemmons, NC
County Forsyth
Latitude 36.0356
Longitude-80.3862
Permittee Listed KJEM, LLC
Legally Responsible David Morgan
Individual
NC Reference No. NCG01-2020-1366
E&SC Plan ID EN1900065
Original NOI 23965
Tracking No.*
Date COC Issued* 04/03/2020
Prior Rescission This field will populate only if CCChas already been rescinded.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 * F Additional Lots/Outparcels Approved - E&SC Revised
r Other Revision(s) to E&SC Plan
r Legally Responsible Individual and/or Site Contact Has Changed
r Multiple Reasons (List)
Addional Ivbre information (e.g., new Site Contact details). If lots are being added, please include specific lot nunbers.
Explanation The Disturbed Area Increased to 2.8 Acres to mass grade adjacent lot same time
as original lot grading.
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 Approval for Clemmons Town Center Outparcel 1
116.03KB
(#EN1900065).pdf
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 knowinglyrenders
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
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* David Morgan
Title * Member/Manager
Organization* KJEM, LLC
Date * 04/09/2021
Email Address* [e-mail]
Errail for confin-ration
Telephone Number* 336-414-1111
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 confirrration
Original Permittee [e-mail]
Email
Original Site Contact [e-mail]
Email
Review Date 04/09/2021
Rescinded Since
Submitted?

Request Date 20210409
Formatted
Review Date 20210409
Formatted