NCC191014_Modification Review_20200227

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 2/26/2020 9:19:13 AM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany 2/27/2020 8:51:04 AM (Construction COC ADD TO FILE Review- NCC191014)
• The task was assigned to Georgoulias, Bethany. The due date is: March 2, 2020 5:00 PM
2/26/2020 9:19 AM

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NORTH CAPCLINA
Emlremmentel Quality
Certificate of NCC191014
Coverage (COC) Enter the Certificate of Coverage Ninber (Use capital letters)
No.*
Information associated with this permit
Project Name
Jacksonville Commons Parks Maintenance Facility Addition - Phase
1
Address
Commons Drive North, Jacksonville, NC
County
Onslow
Latitude
34.7968
Longitude
-77.3928
Permittee Listed
City of Jacksonville
Legally Responsible
Ronald Massey
Individual
NC Reference No.
NCG01-2019-1014
E&SC Plan ID
ONSLO-2019-045
Original NOI
13657
Tracking No.*
Date COC Issued*
07/19/2019
Prior Rescission
This field will populate only if CCChas already been rescinded.
Date
Modification Information:
Reason for f Closed -Out Lots/Outparcels in E&SC Plan
Modification * r Additional Lots/Outparcels Approved - E&SC Revised
r Other Revision(s) to E&SC Plan
f Multiple Reasons (List)
Addional We information if necessary
Explanation
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).

Supporting Upload Supporting Documentation (%vised ESCApproval, (lose -Out Doc, etc.)
Documentation SKM C45820022609020.pdf 261.43KB
Mast be FDFfon-rat
North Carolina General Statute 143-215.66 (1) provides that:
Anyperson who knowinglymakes any false statement, representation, or certification in anyapplication, record, report, plan, or other
documentfiled 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 underthis 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 guiltyofa Class 2 misdemeanor which mayinclude a fine not to exceed ten thousand
dollars ($10,000).
17 I, as an authorized representative, 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.
*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
r'-'V-/�;' /W ¢5 �aL2t
Type Name* Timothy M. Stewart
Title * P.E.
Organization * Parker & Associates, Inc.
Date * 02/26/2020
Email Address* [e-mail]
57ail for Confirmation
Telephone Number* [phone]
Contact Nbrrber if we need to reach you
Review Date 02/27/2020
Request Date 20200226
Formatted
Review Date 20200227
Formatted