NCS000255_Owner Affiliation Change Request_20210813

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 8/13/2021 12:29:13 PM (Owner Affiliation Change Submission)
Approve by McCoy, Suzanne 8/26/2021 2:04:02 PM (Notification to Admin)
• The task was assigned to McCoy, Suzanne 8/13/2021 12:29 PM

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Default Page
NPDES Permit
Enter your MPDES storrrwater pernit nunber or Certificate of Coverage (COC) nunber.
Number*
NCS000255
NCS)00000(orNQG)00000(
Submittor's Name*
Reaseenter your FIRST and LAST narre
Jeffrey Willoughby
Phone Number*
Rease enter your phone nurrber
434-851-0293
Any format is fine.
Email Address *
Rease enter a valid e-rmil address
[e-mail]
A confirmation of submssion will be e-mailed to this address.
Need a copy of the Permit Owner Affiliation Designation Form? You must upload a signed copy of that form below.
Questions? Call Bethany Georgoulias at [phone] or e-mail her at.bethany.georgouliasencdenr.gov.
Completed Form Reaseupload the signed "FbrrritC,vnerAffiliation Designation Forn1'
Upload* NPDES-Owner-Affiliation-Change-20191104-
DEMLR-SW-Downloaded 080821-Morford-081121- 647.22KB
Submitted.pdf
pdf only

Initial Review
Project ID * Reviewer may revise permt nunber below if incorrect.
NCS000255