NCC203533_Modification Review_20210503

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 5/3/2021 11:55:05 AM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany A 5/3/2021 1:14:08 PM (Construction COC ADD TO FILE Review- NCC203533)
The task was assigned to Georgoulias, Bethany A. The due date is: May 6, 2021 5:00 PM
5/3/2021 11:55 AM

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NORTH CAPOLINA
EnYlrenmemf& Qualay
Certificate of NCC203533
Coverage (COC) Enter the Certificate of Coverage Ninber (Use capital letters)
No.*
Information associated with this permit:
Project Name Kalyani-Bharat Forge Gas Pipeline Extension
Address 25 Tabitha Lane, West Sanford, NC
County Lee
Latitude 35.5362
Longitude-79.1552
Permittee Listed Public Services Company of North Carolina, Inc.
Legally Responsible M. Shaun Randall
Individual
NC Reference No. NCG01-2020-3533
E&SC Plan ID
Original NOI
Tracking No.
LEE-2021-003
29921
Date COC Issued* 08/18/2020
Prior Rescission This field will populate only if CCChas already been rescinded.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 We inforrration (e.g., new Site Contact details). If lots are being added, please include specific lot nunbers.
Explanation LIMITS OF DISTURBANCE WAS INCREASED FROM 1.3 ACRES TO 1.5 ACRES
DUE TO EXPANDING THE WORKSPACE
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 (Pevised E&SCApproval, nose -Out Doc, etc.)
Documentation LEE-2021-003_20210501_LOA.pdf 228.2KB
Mist be FDFfornat
North Carolina General Statute 143-215.6B (i) 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 Artide or a rule implementing this Artide; 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 Artide 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).
� 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
1' ct-61111� rtirdrtlt
Type Name* Shaun Randall
Title * General Manager - Gas Operations
Organization * Public Service Company of North Carolina, Inc.
Date * 05/03/2021
Email Address* [e-mail]
En -ail for confirnation
Telephone Number* 704-810-3350
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 confirnation
Original Permittee [e-mail]
Email
Original Site Contact [e-mail]
Email
Review Date 05/03/2021
Rescinded Since
Submitted?

Request Date 20210503
Formatted
Review Date 20210503
Formatted