NCC212212_Modification Review_20210712

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 7/9/2021 7:45:10 AM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany A 7/12/2021 8:14:48 AM (Construction COC ADD TO FILE Review -
NCC212212)
• The task was assigned to Georgoulias, Bethany A. The due date is: July 14, 2021 5:00 PM
7/9/2021 7:45 AM

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NORTH CAPOLINA
EnYlrenmemf& Qualay
Certificate of NCC212212
Coverage (COC) Enter the Certificate of Coverage N nber (Use capital letters)
No.*
Information associated with this permit
Project Name
Natural Gas Pipeline to Serve Laurel Oaks Subdivision
Address
SR 1138/ Harvey Faulk Rd, Commerce Dr., Sanford, NC
County
Lee
Latitude
35.4315
Longitude
-79.1270
Permittee Listed
Public Service Company of North Carolina, Inc
Legally Responsible
Shaun Randall
Individual
NC Reference No.
NCG01-2021-2212
E&SC Plan ID
Lee-2021-027
Original NOI
50103
Tracking No.*
Date COC Issued*
04/15/2021
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This field will populate only if CCChas already been rescinded.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
r Multiple Reasons (List)
Addional We inforrration (e.g., new Site Contact details). If lots are being added, please include specific lot numbers.
Explanation Revised LOD
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 -Out Doc, etc.)
Documentation LEE-2021-027 20210630 LOA.PDF 289.95KB
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
6W C9ra"T Able 1,
Type Name* Shaun Randall
Title * General Manager - Gas Operations
Organization * Public Service Company of North Carolina, Inc.
Date * 07/09/2021
Email Address* [e-mail]
Errail for confirmation
Telephone Number* 7048103350
Contact nun ber if we need to reach you
Note: Original permittee and site contact are copied on modification correspondence.
Additional Email [e-mail]
(Optional) Additional email for confirmation
Original Permittee [e-mail]
Email
Original Site Contact [e-mail]
Email
Review Date 07/12/2021
Rescinded Since
Submitted?

Request Date 20210709
Formatted
Review Date 20210712
Formatted