NCC203355_Modification Review_20210423

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 4/22/2021 11:25:03 AM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany 4/23/2021 8:06:51 AM (Construction COC ADD TO FILE Review- NCC203355)
p Submitter listed different organization, but it is the same legally responsible person who is affiliated with
permitted entity.
• The task was assigned to Georgoulias, Bethany. The due date is: April 27, 2021 5:00 PM
4/22/2021 11:25 AM

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NORTH CAPOLINA
EnYlrenmemf& Qualay
Certificate of NCC203355
Coverage (COC) Enter the Certificate of Coverage Ninber (Use capital letters)
No.*
Information associated with this permit:
Project Name Madison Grove
Address Old NC Highway 41, Town of Wallace, NC
County Duplin
Latitude 35.0000
Longitude-78.0000
Permittee Listed Greenway Residential Development LLC
Legally Responsible Bradley Parker
Individual
NC Reference No. NCG01-2020-3355
E&SC Plan ID
Original NOI
Tracking No.
DUPLI-2020-021
29354
Date COC Issued* 08/06/2020
Prior Rescission This field will populate only if CCChas already been rescinded.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
r Multiple Reasons (List)
Addional MDre information (e.g., new Site Contact details). If lots are being added, please include specific lot nunbers.
Explanation Modifications to original E&SC plan in response to field inspection.
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 -Out Doc, etc.)
Documentation DUPLI-2020-021 Approval Revised 4-16-2021.pdf 231.49KB
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 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
.�"�a1&611.'
Type Name* Bradley Parker
Title * Managing Member
Organization* Madison Grove Apartments, LLC
Date * 04/22/2021
Email Address* [e-mail]
Errail for confirmation
Telephone Number* 980-318-5000
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 04/23/2021
Rescinded Since
Submitted?

Request Date 20210422
Formatted
Review Date 20210423
Formatted