NCC191108_Modification Review (LEG RESP CHANGE)_20201206

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 12/3/2020 11:35:31 AM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany 12/6/2020 1:20:45 PM (Construction COC ADD TO FILE Review- NCC191108)
• The task was assigned to Georgoulias, Bethany. The due date is: December 8, 2020 5:00 PM
12/3/2020 11:35 AM

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NORTH CAPOLINA
EnYlrenmemf& Qnalay
Certificate of NCC191108
Coverage (COC) Enter the Certificate of Coverage Ninber (Use capital letters)
No.*
Information associated with this permit
Project Name
Repair and Improve Bogue Field Wastewater System
Address
Sassafras Road, Bogue, NC
County
Carteret
Latitude
34.6905
Longitude
-77.0347
Permittee Listed
MCAS Cherry Point
Legally Responsible
Charles Schulz
Individual
NC Reference No.
NCG01-2019-1108
E&SC Plan ID
CARTE-2019-033
Original NOI
13998
Tracking No.*
Date COC Issued*
07/29/2019
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This field will populate only if COChas already been rescinded.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 * a Additional Lots/Outparcels Approved - E&SC Revised
O Other Revision(s) to E&SC Plan
r Legally Responsible Individual and/or Site Contact Has Changed
F Multiple Reasons (List)
Legally Responsible Individual Has Changed
Addional IVbre information if needed (e.g., new Site Contact details can be included here)
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 Docurrentation (%vised ERSC Approval, (lose -Out Doc, etc.)
Documentation Repair and Improve Bogue Field Wastewater
96.86KB
System. pdf
Wst be FDFfornat
North Carolina General Statute 143-215.6113 (i) provides that:
Anyperson who knowinglymakes anyfalse 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 knowinglymakes a false statement
of a material fact in a rulemaking proceeding or contested case underthis Article; orwho 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 notto 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:* 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
Type Name* Anthony A. Ference
Title * Deputies Facilities Director By direction of the Commanding Officer
Organization* MCAS Cherry Point
Date * 12/03/2020
Email Address* [e-mail]
Emil for confin-ration
Telephone Number* 252-466-3807
Contact nunber if we need to reach you
Note: Original permittee and site contact are copied on modification correspondence.
Additional Email [e-mail]
(Optional) Additional en -ail for confin-ation
Original Permittee [e-mail]
Email
Original Site Contact [e-mail]
Email
Review Date 12/06/2020
Rescinded Since
Submitted?

Request Date 20201203
Formatted
Review Date 20201206
Formatted