NCC215916_Modification Review_20230925

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by Anonymous User 9/21/2023 2:45:09 PM (ADD TO FILE Submittal)
Approve by bethany.georgoulias 9/25/2023 9:15:33 AM (Construction COC ADD TO FILE Review-NCC215916)
0 Approval indicated on plan sheet uploaded. Legally responsible person updated 9/25/2023.
• The task was assigned to bethany.georgoulias.The due date is: September 26,2023 5:00 PM
9/21/2023 2:45:09 PM

Ago DEQMODIFICATION
Permit for Construction Activities 0i0rl
0000
Certificate of NCC215916
Coverage(COC)No.* Enter the Certificate of Coverage Number(Use capital letters)
Information associated with this permit:
Project Name FDB Project Galaxy-Early Grading
Address 11751 Holly Springs New Hill Road, Holly Springs, NC
County Wake
Latitude 35.6553
Longitude -78.8735
Permittee Listed Fujifilm Diosynth Biotechnologies USA, Inc.
Legally Responsible Thomas Schmalzbauer
Individual At the time of Modification Request(not looked up again at review)
NC Reference No. NCG01-2021-5916
E&SC Plan ID 21-2021
Original NOI Tracking 69506
No.*
Date COC Issued* 10/28/2021
Prior Rescission Date This field will populate only if COC has already been rescinded.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) Expanded project area and change to Legally Responsible Person
Addional Explanation
More information(e.g.,new Site Contact details).If lots are being added,please include specific lot numbers.
Project boundaries expanded,approved by local AHJ,and new responsible person
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.)
Fuji_EastContractorParking_RevisedApprovedSheets.pdf 16.03MB
NCDEQ-Legally-Responsible-Change-Form-Signed.pdf 620.26KB
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 143-215.613(1)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
oxem?'"alte ro
Type Name* Jordan Ulrich
Title* Vice President of Project Delivery
Organization* Fujifilm Diosynth Biotechnologies USA, Inc.
Date* 09/21/2023
Email Address* [e-mail]
Email for confirmation
Telephone Number* 4192669596
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 09/25/2023
Rescinded Since
Submitted?