NCC230305_Modification Review_20230321

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 3/17/2023 12:47:29 PM (ADD TO FILE Submittal)
Approve by bethany.georgoulias 3/21/2023 11:03:17 AM (Construction COC ADD TO FILE Review - NCC230305)
• The task was assigned to bethany.georgoulias. The due date is: March 22, 2023 5:00 PM
3/17/2023 12:47:30 PM

E
Certificate of NCC230305
Coverage (COC) No.* Enter the Certificate of Coverage Number (Use capital letters)
Information associated with this permit:
Project Name McDonald's - Wendell Falls Site
Address 5941 Taylor Road, Wendell, NC
County Wake
Latitude 35.7765
Longitude-78.4340
Permittee Listed McDonald's USA, LLC
Legally Responsible Leo Van Buuren
Individual
NC Reference No. NCG01-2023-0305
E&SC Plan ID SEC-087178-2022
Original NOI Tracking 125779
No.*
Date COC Issued* 02/06/2023
Prior Rescission Date This field will populate only if COC has already been rescinded.
Modification Information:
Reason for Modification*
Closed -Out Lots/Outparcels in E&SC Plan
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.
Added area for materail storage and staging area
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 Documentation
Upload Supporting Documentation (Revised E&SC Approval, Close -Out Doc, etc.)
McDonalds Wendell
Falls_Revision_MUNICIPALWatershedManagementApproval_V.3_3- 326.22KB
17-2023.pdf
Must be PDF format
Is this project funded with ARPA (American Rescue Plan Act) grant funds?
No
Yes
This question was added to the eNOl on 2/3/2023 and will not be answered in applications submitted prior to that date.
North Carolina General Statute 143-215.6B (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
"u,
Type Name* Leo Van Buuren
Title* Area Construction Manager
Organization* McDonald's USA, LLC
Date * 03/17/2023
Email Address* [e-mail]
Email for confirmation
Telephone Number* 9199312845
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 03/21/2023
Rescinded Since
Submitted?