NCC204915_Modification Review (LEG RESP CHANGE)_20220627

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 6/22/2022 8:56:36 AM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany A 6/27/2022 9:19:44 PM (Construction COC ADD TO FILE Review - NCC204915)
* Updated Legally responsible individual on 6/21/2022. NOT Certification form included, but permittee
will be notified that we cannot process an Notice of Termination request as a modification.
The task was assigned to Georgoulias, Bethany A. The due date is: June 27, 2022 5:00 PM
6/22/2022 8:56 AM

Georgoulias, Bethany
From: Georgoulias, Bethany
Sent: Monday, June 27, 2022 9:22 PM
To: [e-mail]
Cc: [e-mail]; [e-mail];
[e-mail]
Subject: RE: Construction SW Mod Request - NOT Certification Form Included / NOT Must be
Submitted Separately
Attachments: DEMLR ChangeForm_Termination_NCC204915_NC55.pdf
Importance: High
Good evening,
I am working through several requests to update the legally responsible individual to you, Andrew Moore, on
construction stormwater permits.
For this one (NC 55 8" Connection Gas Pipeline Extension), I noticed that a Notice of Termination (NOT) Certification
form was also included (p. 3 of the attachment). However, a Notice of Termination must be submitted separately
through this link:
https://edocs.deg.nc.gov/Forms/NCGOI-Termination
Until an NOT is submitted and approved, this COC will remain active. Please let us know if you have any questions.
Best regards,
Bethany Georgoulias (she/her)
Environmental Engineer
Stormwater Program, Division of Energy, Mineral, and Land Resources
N.C. Department of Environmental Quality
919 707 3641 office
[e-mail]
512 N. Salisbury Street, Raleigh, NC 27604 (location)
1612 Mail Service Center, Raleigh, NC 27699-1612 (mailing)
Website: http://deq.nc.gov/about/divisions/energy-mineral-land-resources/stormwater
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties
Based on the current guidance to minimize the spread of COVID-19, the Department of Environmental Quality has
adjusted operations to protect the health and safety of the staff and public. Many employees are working remotely or
are on staggered shifts. To accommodate these staffing changes, all DEQ office locations are limiting public access to
appointments only. Please check with the appropriate staff before visiting our offices, as we may be able to handle your

requests by phone or email. We appreciate your patience as we continue to serve the public during this challenging
time.
From: [e-mail] <[e-mail]>
Sent: Wednesday, June 22, 2022 8:57 AM
To: [e-mail]
Cc: [e-mail]; [e-mail];
[e-mail]
Subject: Construction SW Modification Request Received
Thank you for submitting a Modification request for NC-55 8-In. Connection in Wake County, Certificate of Coverage
(COC) no. NCC204915.
Modification Reason: Legally Responsible Individual and/or Site Contact Has Changed
Additional Details (if provided):
If your submittal is accepted, you will receive e-mail confirmation. You will also be notified if additional information is
needed or if the modification request or documents cannot be accepted.
If you have any questions, please contact [e-mail].
Be sure to add [e-mail] to your contacts to avoid future a -mails about this application from going into
Spam filters.
The NC DEMLR Stormwater Program
512 N. Salisbury Street, Archdale Building 6th Floor, 1612 Mail Service Center, Raleigh, NC 27699-1612
This email was automatically generated by Laserfiche. Please do not respond to this email address, as responses are not
monitored.

Certificate of NCC204915
Coverage (COC) No.* Enter the Certificate of Coverage Number (Use capital letters)
Information associated with this permit:
Project Name NC-55 8-In. Connection
Address NC-55, Cary, NC
County Wake
Latitude 35.8220
Longitude-78.8740
Permittee Listed Dominion Energy of North Carolina, Inc.
Legally Responsible Shaun Randall
Individual
NC Reference No. NCG01-2020-4915
E&SC Plan ID WAKE-2021-030
Original NOI Tracking 34489
No. *
Date COC Issued* 10/30/2020
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
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 DEMLR
1.41 M B
ChangeForm_Termination_NCC204915_NC55.pdf
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 NCG010000 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 * 06/22/2022
Email Address* [e-mail]
Email for confirmation
Telephone Number* 704-810-3259
Contact number 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 06/27/2022
Rescinded Since
Submitted?