NCC201987_Modification Review_20210513

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 5/6/2021 8:55:54 AM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany A 5/13/2021 10:26:08 AM (Construction COC ADD TO FILE Review -
NCC201987)
p Separate NOI was submitted for this phase of the project but will be added as a modification to this
COC instead. NOI no. 52114 will be canceled.
• The task was assigned to Georgoulias, Bethany A. The due date is: May 11, 2021 5:00 PM
5/6/2021 8:56 AM

Y . Ta4M1
NORTH CAPOLINA
EnYlrenmemf& Qnalay
Certificate of NCC201987
Coverage (COC) Enter the Certificate of Coverage Ninber (Use capital letters)
No.*
Information associated with this permit
Project Name
Kaleideum
Address
120 West 3rd Street, Winston-Salem, NC, NC
County
Forsyth
Latitude
36.0970
Longitude
-80.2460
Permittee Listed
Forsyth County
Legally Responsible
Damon Sanders -Pratt
Individual
NC Reference No.
NCG01-2020-1987
E&SC Plan ID
Forsy-2020-021
Original NOI
25459
Tracking No.*
Date COC Issued*
05/14/2020
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This field will populate only if CCChas already been rescinded.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
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 ESCApproval, (lose -Cut Doc, etc.)
Documentation Phase II Erosion Control Permit.pdf 205.32KB
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 NCG010000 General Permit. For more information on signatory requirements, see Part IV, Section B,
Item (6) of that permit.
Signature
Type Name* Damon Sanders -Pratt
Title * Deputy County Manager
Organization* Forsyth County
Date * 05/06/2021
Email Address* [e-mail]
Errail for confirmation
Telephone Number* 336-703-2008
Contact nurrber if we need to reach you
Note: Original permittee and site contact are copied on modification correspondence.
Additional Email Additional email for confirmation
(Optional)
Original Permittee [e-mail]
Email
Original Site Contact [e-mail]
Email
Review Date 05/13/2021
Rescinded Since
Submitted?

Request Date 20210506
Formatted
Review Date 20210513
Formatted