NCC204928_Modification Review_20210903

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 9/1/2021 6:03:07 AM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany A 9/3/2021 1:23:10 PM (Construction COC ADD TO FILE Review- NCC204928)
The task was assigned to Georgoulias, Bethany A. The due date is: September 6, 2021 5:00 PM
9/1/2021 6:03 AM

Y . Ta4M1
NORTH CAPOLINA
EnYlrenmemf& Qualay
Certificate of NCC204928
Coverage (COC) Enter the Certificate of Coverage N nber (use capital letters)
No.*
Information associated with this permit:
Project Name Rocky Mount Mills Assisted Living
Address River Dr, Rocky Mount, NC
County Nash
Latitude 35.9554
Longitude-77.8086
Permittee Listed Carolina Commercial Contractors, LLC
Legally Responsible W. Carter Keller
Individual
NC Reference No. NCG01-2020-4928
E&SC Plan ID 2020-01446
Original NOI 34487
Tracking No.*
Date COC Issued* 11/02/2020
Prior Rescission This field will populate only if COChas already been rescinded.
Date
Modification Information:
Reason for r Closed -Out Lots/Outparcels in E&SC Plan
Modification * F Additional Lots/Outparcels Approved - E&SC Revised
r Other Revision(s) to E&SC Plan
r Legally Responsible Individual and/or Site Contact Has Changed
r Multiple Reasons (List)
Addional We information (e.g., new site Contact details). If lots are being added, please include specific lot nunbers.
Explanation One Additional Acre has been approved for land disturbance and grading. The
extra area has been proposed on the perimeter of the project in order to install
extra fill material. Extra soil is present on site, due to the Brownsfield requirements.
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 IRSCApproval, (lose -Out Doc, etc.)
Documentation LOA- Rev1 - 2021-08-23 Rocky Mount Assisted
224.57KB
Living Additoinal Acreage ESC Approval Letter.pdf
Mast be RYfornat
North Carolina General Statute 143-215.6B (i) 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).
rJ 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
-17 cl i
Type Name* W. Carter Keller
Title * Manager
Organization* Carolina Commercial Contractors, LLC
Date * 09/01 /2021
Email Address* [e-mail]
En -ail for confirnation
Telephone Number* 919-708-8987
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 09/03/2021

Rescinded Since
Submitted?
Request Date 20210901
Formatted
Review Date 20210903
Formatted