NCC192835_Modification Review_20210329

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 3/26/2021 3:29:27 PM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany 3/29/2021 7:33:55 AM (Construction COC ADD TO FILE Review- NCC192835)
p Airport Director has changed. Revievver will contact submitter about filling out change of Legally
Responsible Owner form/making contact changes.
• The task was assigned to Georgoulias, Bethany. The due date is: March 31, 2021 5:00 PM
3/26/2021 3:29 PM

Y. ,
NORTH CAPOLINA
EnYlrenmemf& Qnalay
Certificate of NCC192835
Coverage (COC) Enter the Certificate of Coverage Ninber (Use capital letters)
No.*
Information associated with this permit
Project Name
Fayetteville Regional Airport Terminal Improvements - Phase 2
Address
400 Airport Road, Suite 1, Fayetteville, NC
County
Cumberland
Latitude
35.0000
Longitude
-79.0000
Permittee Listed
City of Fayetteville - Fayetteville Regional Airport
Legally Responsible
Bradley Whited
Individual
NC Reference No.
NCG01-2019-2835
E&SC Plan ID
CUMBE-2020-047
Original NOI
18587
Tracking No.*
Date COC Issued*
11/20/2019
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This field will populate only if COChas already been rescinded.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 and/or Site Contact Has Changed
f Multiple Reasons (List)
Addional IVbre information (e.g., new Site Contact details). If lots are being added, please include specific lot nuabers.
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 -Out Doc, etc.)
Documentation Certificate of Coverage.pdf 36.13KB
CUMBE-2020-047 Approval.pdf 85.15KB
Financial Responsibility Modification Signed.pdf 437.11 KB
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 A tide 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 Artide 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 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* Alvester Coleman
Title * Airport Director
Organization* City of Fayetteville Regional Airport
Date * 03/26/2021
Email Address* [e-mail]
Errail for confirmation
Telephone Number* 910-433-1160
Contact nun ber 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 03/29/2021
Rescinded Since
Submitted?

Request Date 20210326
Formatted
Review Date 20210329
Formatted