NCC211688_Modification Review_20210806

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 8/5/2021 10:44:52 AM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany A 8/6/2021 8:59:46 AM (Construction COC ADD TO FILE Review- NCC211688)
The task was assigned to Georgoulias, Bethany A. The due date is: August 10, 2021 5:00 PM
8/5/2021 10:45 AM

Y . Ta4M1
w,
NORTH CAPOLINA
EnYlrenmemf& Qualay
Certificate of NCC211688
Coverage (COC) Enter the Certificate of Coverage Ninber (Use capital letters)
No.*
Information associated with this permit:
Project Name PNG Kinston City Gate Regulator Station
Address Cunningham Road, Kinston, NC
County Lenoir
Latitude 35.2921
Longitude-77.5577
Permittee Listed Piedmont Natural Gas Company, Inc.
Legally Responsible Adam Pollak
Individual
NC Reference No. NCG01-2021-1688
E&SC Plan ID
Original NOI
Tracking No.
LENOI-2021-014
48053
Date COC Issued* 03/26/2021
Prior Rescission This field will populate only if CCChas already been rescinded.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 Ivbre information (e.g., new Site Contact details). If lots are being added, please include specific lot nunbers.
Explanation Additional 0.5 acres near driveway entrance being added to existing project.
Erosion and sedimentation control plan approval dated 8/4/2021 uploaded.
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, Close -Out Doc, etc.)
Documentation Lenoi-2021-014 PNG Kinston City Gate Regulator
825.56KB
Station - 08042021.pdf
Mast be FDFformat
North Carolina General Statute 143-215.66 (1) provides that:
Anyperson who knowinglymakes anyfalse 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 knowinglymakes a false statement
of a material fact in a rulemaking proceeding or contested case underthis Article; orwho 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 notto 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 NCGO10000 General Permit. For more information on signatory requirements, see Part IV, Section B,
Item (6) of that permit.
Signature
Type Name* Adam Pollak
Title * Project Manager
Organization* Piedmont Natural Gas
Date * 08/05/2021
Email Address* [e-mail]
Errail for confirmation
Telephone Number* 9524562648
Contact number 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 08/06/2021
Rescinded Since
Submitted?

Request Date 20210805
Formatted
Review Date 20210806
Formatted