NCC232648_Modification Review_20230926

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by Anonymous User 9/25/2023 10:55:03 AM (ADD TO FILE Submittal)
Approve by bethany.georgoulias 9/26/2023 7:01:13 AM (Construction COC ADD TO FILE Review-NCC232648)
•City of Winston Salem approval noted on uploaded plan sheet.
• The task was assigned to bethany.georgoulias.The due date is: September 28,2023 5:00 PM
9/25/2023 10:55:05 AM

Ago DEQMODIFICATION
Permit for Construction Activities 0itltl
0000
Certificate of NCC232648
Coverage(COC)No.* Enter the Certificate of Coverage Number(Use capital letters)
Information associated with this permit:
Project Name Chick-fil-A Peace Haven Road
Address 1925 N Peace Haven Road,Winston-Salem, NC
County Forsyth
Latitude 36.1178
Longitude -80.3129
Permittee Listed Chick-fil-A INC
Legally Responsible Kimberly Johnson
Individual At the time of Modification Request(not looked up again at review)
NC Reference No. NCG01-2023-2648
E&SC Plan ID EN2300087
Original NOI Tracking 157960
No.*
Date COC Issued* 09/01/2023
Prior Rescission Date This field will populate only if COC has already been rescinded.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.
For the Chick-fil-A located at 1925 Peace Haven Road,CFA has made a slight modification(Revision)
we have pushed the back the proposed parking spaces so they can align with the existing ones in the right and
also to make sure our parking spaces aren't encroaching to the existing drive aisle,
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.)
CFA FSU 1186 Peace Haven NC-Permit Set C3.2.pdf 882.28KB
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
A�tlj C"&'Y✓oar
Type Name* Kimberly Johnson
Title* Vice President
Organization* Chick-fil-A
Date* 09/25/2023
Email Address* [e-mail]
Email for confirmation
Telephone Number* 4076455008
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 09/26/2023

Rescinded Since
Submitted?