NCC193032_Modification Review (LEG RESP CHANGE)_20211208

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 12/3/2021 10:33:53 AM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany A 12/8/2021 3:19:58 PM (Construction COC ADD TO FILE Review - NCC193032)
* Legally responsible individual was updated.
The task was assigned to Georgoulias, Bethany A. The due date is: December 8, 2021 5:00 PM
12/3/2021 10:33 AM

JjAl'i
NORTH LAPOLINA
Cn iranmenfet Quality
Certificate of NCC193032
Coverage (COC) No.* Enter the Certificate of Coverage Number (Use capital letters)
Information associated with this permit:
Project Name The Pilot at Sedgefield - Water and Sewer Improvements
Address 5300 High Point Road, Greensboro, NC
County Guilford
Latitude 36.0197
Longitude-79.8842
Permittee Listed KSL Sedgefield Pilot, LLC
Legally Responsible Craig Taylor
Individual
NC Reference No. NCG01-2019-3032
E&SC Plan ID GUILF-2020-016
Original NOI Tracking 19067
No. *
Date COC Issued * 12/10/2019
Prior Rescission Date This field will populate only if COC has already been rescinded.
Modification Information:
Reason for Closed -Out Lots/Outparcels in E&SC Plan
Modification* Additional Lots/Outparcels Approved - E&SC Revised
Other Revision(s) to E&SC Plan
• Legally Responsible Individual and/or Site Contact Has Changed
Multiple Reasons (List)
Addional Explanation More information (e.g., new Site Contact details). If lots are being added, please include specific lot numbers.
changing LRP
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 (Revised E&SC Approval, Close -Out Doc, etc.)
Documentation 12.01.21 SP-Legally-Responsible-Change-Form.pdf 976.55KB
Must be PDF format
North Carolina General Statute 143-215.613 (i) provides that:
Any person who knowingly makes any false statement, representation, or certification in any application, record, report, plan, or other document
filed 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 under this 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 guilty of a Class 2 misdemeanor which may include 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:* The Legally Responsible Individual
• 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* Shanel Goodwin
Title* Project Coordinator
Organization * Kisco Senior Living
Date * 12/03/2021
Email Address* [e-mail]
Email for confirmation
Telephone Number* 7608047042
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 12/08/2021
Rescinded Since
Submitted?
Request Date 20211203
Formatted

Review Date 20211208
Formatted