NCC205281_Modification Review_20210422

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 4/20/2021 4:48:04 PM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany 4/22/2021 10:15:32 AM (Construction COC ADD TO FILE Review- NCC205281)
• The task was assigned to Georgoulias, Bethany. The due date is: April 23, 2021 5:00 PM
4/20/2021 4:48 PM

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NORTH CAPOLINA
EnYlrenmemf& Qnalay
Certificate of
NCC205281
Coverage (COC)
Enter the Certificate of Coverage Ninber (Use capital letters)
No.*
Information associated
with this permit:
Project Name
Line 328 Extension
Address
Hilltop Drive, Winston-Salem, NC
County
Forsyth
Latitude
36.1255
Longitude
-80.3451
Permittee Listed
Piedmont Natural Gas
Legally Responsible
Pinkney Bynum
Individual
NC Reference No.
NCG01-2020-5281
E&SC Plan ID
FORSY-2021-005
Original NOI
36113
Tracking No.*
Date COC Issued*
11/24/2020
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This field will populate only if COChas already been rescinded.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 * 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
f Multiple Reasons (List)
Addional IVbre information (e.g., new Site Contact details). If lots are being added, please include specific lot nurTbers.
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 FORSY-2021-005_20210420_A-M.pdf 5.37MB
Revised ESC Plan Sheet for Tie -in —Approved by
1.3MB
NCDEQ 04202014.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 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
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* Pinkney Bynum
Title * Project Manager
Organization* Piedmont Natural Gas
Date * 04/20/2021
Email Address* [e-mail]
Errail for confirmation
Telephone Number* 7047314399
Contact nun ber 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 04/22/2021
Rescinded Since
Submitted?

Request Date 20210420
Formatted
Review Date 20210422
Formatted