NCC203615_Modification Review (LEG RESP CHANGE)_20210616

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 6/16/2021 12:32:29 PM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany A 6/16/2021 3:02:27 PM (Construction COC ADD TO FILE Review -
NCC203615)
* Legally responsible individual updated (confirmation sent).
• The task was assigned to Georgoulias, Bethany A. The due date is: June 21, 2021 5:00 PM
6/16/2021 12:32 PM

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NORTH CAPOLINA
EnYlrenmemf& Qualay
Certificate of NCC203615
Coverage (COC) Enter the Certificate of Coverage Ninber (Use capital letters)
No.*
Information associated with this permit
Project Name
Calabash Station
Address
Calabash Road INK Calabash, NC
County
Brunswick
Latitude
33.9207
Longitude
-78.5994
Permittee Listed
Calabash Station, LLC
Legally Responsible
Kerry Avant
Individual
NC Reference No.
NCG01-2020-3615
E&SC Plan ID
BRUNS-2020-082
Original NOI
30084
Tracking No.*
Date COC Issued*
08/20/2020
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This field will populate only if CCChas already been rescinded.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
O Other Revision(s) to E&SC Plan
r Legally Responsible Individual and/or Site Contact Has Changed
F Multiple Reasons (List)
Legally Responsible Individual and/or Site Contact Has Changed
and Revision(s) to E&SC Plan
Addional IVbre information (e.g., new Site Contact details). If lots are being added, please include specific lot nunbers.
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 (Pevised E&SCApproval, rose -Out Doc, etc.)
Documentation 210610_Legally Responsible Individual Change
675.03KB
Form.pdf
BRUNS-2020-082 Approval Revised 5-17-2021.pdf 232.15KB
Mist be FDFfornat
North Carolina General Statute 143-215.613 (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 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).
� 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
Type Name* David Vannoy
Title * Manager
Organization* Calabash Station, LLC
Date * 06/16/2021
Email Address* [e-mail]
En -ail for confirnation
Telephone Number* 910-824-1357
Contact nunber ff 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 06/16/2021
Rescinded Since
Submitted?

Request Date 20210616
Formatted
Review Date 20210616
Formatted