NCC190963_Modification Review_20201118

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 11/17/2020 2:55:05 PM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany 11/18/2020 7:13:18 AM (Construction COC ADD TO FILE Review- NCC190963)
* Note - annual fee for 2020 has been paid.
• The task was assigned to Georgoulias, Bethany. The due date is: November 20, 2020 5:00 PM
11/17/2020 2:55 PM

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NORTH CAPOLINA
EnYlrenmemf& Qnalay
Certificate of NCC190963
Coverage (COC) Enter the Certificate of Coverage N nber (Use capital letters)
No.*
Information associated with this permit
Project Name
Northern Lights
Address
Northwest Road NE (SR 1419), Northwest, NC
County
Brunswick
Latitude
34.2946
Longitude
-78.1438
Permittee Listed
Northern Lights Development Company, LLC
Legally Responsible
Jeffrey Malpass
Individual
NC Reference No.
NCG01-2019-0963
E&SC Plan ID
BRUNS-2019-089
Original NOI
13473
Tracking No.*
Date COC Issued*
07/16/2019
Prior Rescission
This field will populate only if COChas already been rescinded.
Date
Modification Information:
Reason for r Closed -Out Lots/Outparcels in E&SC Plan
Modification * r Additional Lots/Outparcels Approved - E&SC Revised
F Other Revision(s) to E&SC Plan
r Legally Responsible Individual Has Changed
f Multiple Reasons (List)
Addional IVbre 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). For changes to the legally responsible individual, you must upload this form.

Supporting Upload Supporting Documentation (%vised ESCApproval, (lose -Cut Doc, etc.)
Documentation BRUNS-2019-089 Approval Revised 11-12-2020.pdf 291.34KB
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 e)ceed ten thousand
dollars ($10,000).
rJ 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:* r The Legally Responsible Individual
f 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
.1-1 KI 13 peA (4�a
Type Name* Jeffrey Malpass
Title * Manager
Organization * Northern Lights Development Company, LLC
Date * 11 /17/2020
Email Address* [e-mail]
Bmail for confirrration
Telephone Number* 910-520-5061
Contact nun ber 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 11/18/2020
Rescinded Since
Submitted?

Request Date 20201117
Formatted
Review Date 20201118
Formatted