NCC205388_Modification Review_20211013

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 10/8/2021 12:49:40 PM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany A 10/13/2021 8:49:51 AM (Construction COC ADD TO FILE Review -
NCC205388)
* Legally responsible individual updated to Andrew Moore (form provided by e-mail on 10112 and added
to the permit file).
• The task was assigned to Georgoulias, Bethany A. The due date is: October 13, 2021 5:00 PM
10/8/2021 12:49 PM

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NORTH CAPOLINA
EnYlrenmemf& Qualay
Certificate of NCC205388
Coverage (COC) Enter the Certificate of Coverage Ninber (Use capital letters)
No.*
Information associated with this permit:
Project Name Wendel l-Knightdale Connection
Address 9820 SR 1007, Town of Knightdale, NC
County Wake
Latitude 35.7470
Longitude-78.4450
Permittee Listed Public Service Company of North Carolina, Inc.
Legally Responsible Shaun Randall
Individual
NC Reference No. NCG01-2020-5388
E&SC Plan ID
Original NOI
Tracking No.
WAKE-2021-034
36784
Date COC Issued* 11/24/2020
Prior Rescission This field will populate only if CCChas already been rescinded.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 * 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 Addition of workspace and thus increase in limits of disturbance. Also, modification
of legally responsible individual.
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, nose -Out Doc, etc.)
Documentation WAKE-2021-034_20211005_LOA.pdf 317.58KB
Mist be FDFfornat
North Carolina General Statute 143-215.6B (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 Artide or a rule implementing this Artide; 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 Artide 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* Andrew Moore
Title * Director - Engineering & Construction
Organization * Public Service Company of North Carolina, Inc.
Date * 10/08/2021
Email Address* [e-mail]
En -ail for confirnation
Telephone Number* 704-810-3259
Contact nunber if 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 10/13/2021
Rescinded Since
Submitted?

Request Date 20211008
Formatted
Review Date 20211013
Formatted