NCC204866_Modification Review (LEG RESP CHANGE)_20210610

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 6/9/2021 3:02:39 PM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany A 6/10/2021 3:24:28 PM (Construction COC ADD TO FILE Review -
NCC204866)
* Legally Responsible Change form submitted by Hannah Banks via email on 611012021.
• The task was assigned to Georgoulias, Bethany A. The due date is: June 14, 2021 5:00 PM
6/9/2021 3:02 PM

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NORTH CAPOLINA
EnYlrenmemf& Qualay
Certificate of NCC204866
Coverage (COC) Enter the Certificate of Coverage Ninber (Use capital letters)
No.*
Information associated with this permit:
Project Name Elementary School 51 Pond Breach
Address Woods Creek Road, Holly Springs, NC
County Wake
Latitude 35.6810
Longitude-78.8830
Permittee Listed Wake County Board of Education
Legally Responsible Don Haydon Jr
Individual
NC Reference No. NCG01-2020-4866
E&SC Plan ID
Original NOI
Tracking No.
WAKE-2020-091
34315
Date COC Issued* 10/29/2020
Prior Rescission This field will populate only if CCChas already been rescinded.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 * a Additional Lots/Outparcels Approved - E&SC Revised
r Other Revision(s) to E&SC Plan
F Legally Responsible Individual and/or Site Contact Has Changed
r Multiple Reasons (List)
Addional Ivbre information (e.g., new Site Contact details). If lots are being added, please include specific lot nunbers.
Explanation Additional limits of disturbance were added to this plan, financial representative
has changed
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 (Fevised E&SCApproval, nose -Out Doc, etc.)
Documentation WAKE-2021-019 20210525 LOA.PDF 288.72KB
WAKE-2021-079 20210525 COA.PDF 327.87KB
Mast be FDFfornat
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
r 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
Type Name* David Neter
Title * Chief Business Officer
Organization * Wake County Public Schools
Date * 06/09/2021
Email Address* [e-mail]
Errail for confirnation
Telephone Number* 9196940232
Contact nunter if we need to reach you
Note: Original permittee and site contact are copied on modification correspondence.
Additional Email Additional en -ail for confirnation
(Optional)
Original Permittee [e-mail]
Email
Original Site Contact [e-mail]
Email
Review Date 06/10/2021
Rescinded Since
Submitted?

Request Date 20210609
Formatted
Review Date 20210610
Formatted