NCC210805_Modification Review_20210604

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 6/4/2021 10:18:47 AM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany A 6/4/2021 10:52:09 AM (Construction COC ADD TO FILE Review -
NCC210805)
• The task was assigned to Georgoulias, Bethany A. The due date is: June 9, 2021 5:00 PM
6/4/2021 10:18 AM

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NORTH CAPOLINA
EnYlrenmemf& Qnalay
Certificate of
NCC210805
Coverage (COC)
Enter the Certificate of Coverage Ninber (Use capital letters)
No.*
Information associated
with this permit:
Project Name
Kerwin Circle Tap Line
Address
W. Mountain St., Kernersville, NC
County
Forsyth
Latitude
36.1226
Longitude
-80.1650
Permittee Listed
Duke Energy Carolinas, LLC
Legally Responsible
Randy Veltri
Individual
NC Reference No.
NCG01-2021-0805
E&SC Plan ID
FORSY-2021-025
Original NOI
43082
Tracking No.*
Date COC Issued*
02/10/2021
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This field will populate only if CCChas already been rescinded.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 Docurrentation (%vised IBSCApproval, (lose -Out Doc, etc.)
Documentation FORSY-2021 -
4AMB
025_20210524_Approval_Express_Revision. pdf
Wst be FDFforrrat
North Carolina General Statute 143-215.6113 (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 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 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 NCG010000 General Permit. For more information on signatory requirements, see Part IV, Section B,
Item (6) of that permit.
Signature
Type Name* Randy Veltri
Title * Manager, Permitting
Organization* Duke Energy Carolinas, LLC
Date * 06/04/2021
Email Address* [e-mail]
En -ail for confin-ration
Telephone Number* 9803733634
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 confin-ation
Original Permittee [e-mail]
Email
Original Site Contact [e-mail]
Email
Review Date 06/04/2021
Rescinded Since
Submitted?

Request Date 20210604
Formatted
Review Date 20210604
Formatted