NCC212515_Modification Review_20211001

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 9/30/2021 4:47:07 PM (ADD TO FILE Submittal)
Approve by Georgoulias, Bethany A 10/1/2021 12:21:50 PM (Construction COC ADD TO FILE Review -
NCC212515)
• The task was assigned to Georgoulias, Bethany A. The due date is: October 5, 2021 5:00 PM
9/30/2021 4:47 PM

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NORTH CAPOLINA
EnYlrenmemf& Qnalay
Certificate of NCC212515
Coverage (COC) Enter the Certificate of Coverage Ninber (Use capital letters)
No.*
Information associated with this permit
Project Name
The Home Place of Southport
Address
NC 211 (Southport -Supply Rd), Smithville Township, NC
County
Brunswick
Latitude
33.9489
Longitude
-78.0369
Permittee Listed
The Home Place of Wilmington, LLC
Legally Responsible
Terrance Ando
Individual
NC Reference No.
NCG01-2021-2515
E&SC Plan ID
BRUNS-2021-049
Original NOI
50853
Tracking No.*
Date COC Issued*
04/29/2021
Prior Rescission
This field will populate only if CCChas already been rescinded.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 E&SCApproval, (lose -Out Doc, etc.)
Documentation BRUNS-2021-049 Approval Revised 9-28-2021.pdf 307.18KB
Mast be FDFfon-rat
North Carolina General Statute 143-215.66 (1) 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).
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* Terrance Ando
Title * Member/Manager
Organization* The Home Place of Wilmington, LLC
Date * 09/30/2021
Email Address* [e-mail]
Errail for confirmation
Telephone Number* 910-443-6739
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 10/01/2021
Rescinded Since
Submitted?

Request Date 20210930
Formatted
Review Date 20211001
Formatted