NCG080026_Email RE Owner Affiliation and Contact Updates_20211215

Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resourc (?S
X'!!PONIO #1�L 'j,ki�• (Individual Legally Responsible for Permit)
Use this form if there has been:
FOR AGENCY USE ONLY
Date Received
Year
Month
Day
NO CHA FGE in facility ownership or facility name, but the individual
who is legally responsible for the permit has changed.
If the name of the facility has changed, or if the ownershir of the facility has changed,
do NOT use this form. Instead, you must fill out a Name -Ownership Change Form
and submit the completed form with all required documentation.
What does "legally responsible individual' mean?
The person is either:
• the responsible corporate officer (for a corporation);
• the principle executive officer or ranking elected official (for a municipality, state, federal or other public
agency);
• the general partner or proprietor (for a partnership or sole proprietorship);
• or, the duly authorized representative of one of the above.
1) Enter the permit number for which this change in Legally Responsible Individual ("Owner Affiliation")
applies:
Individual Permit (00 Certificate of Coverage or No Exposure
N C S N C G'Q (K O O %
2) Facility Information:
Facility name: W aKe. c. 601 - Puto`IG �ckno 1 J 5-f toA
Company/Owner Organization: C.o v wi' vb i G va vvt
Facility address: vq,(44
Address
i a(e,Ny"CC 2 6(0
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
htt )s://dec .nc.,-,ov/about/divislons/enert,v-mineral-land-resources/ener,,%-mineral-land- )ermits/n des-industrial-
ro ram and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: (ooLd KYN&I ler
First MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: NU(.-Pkau 1 _ S ]AV/' K
First MI Last
Page .I of 2
S W[J-0WNERAFFU_4Nov2019

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
Title
Mailing Address
o. Y� Y'G
City State Zip
(gig ) 8s& Size, t4sLdyw-e LjcPSS.NzT
Telephone E-mail Address
Fax Number
5) Reason for this change:
A result of: ❑ Employee or management change
Inappropriate or incorrect designation before
❑ Other
If other please explain:
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
I, dA74AO SLAVtLc , attest that this application for this change in Owner Affiliation
(person legally responsible for the permit) has been reviewed and is accurate and complete to the best of my
knowledge. I understand that if all required parts of this form are not completed, this change may not be
processed.
jZ
Signature Date
PLEASE SEND THE COMPLETED FORM TO:
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
For more information or staff contacts, please call [phone] or visit the website
at: litt )://deg.iic.(ov/abotit/(Iivisioiis/eiier,v-mineral-land-resources/storniwatci*
Page 2 of 2
S WU-0WNERAFFIL-4Nov2019

Georgoulias, Bethany
From: Todd Kneller -Staff - EnvironmentGrounds <[e-mail]>
Sent: Wednesday, December 15, 2021 10:10 AM
To: Georgoulias, Bethany
Cc: Carson, Brittany; Nathan Slavik _ Staff - MaintenanceOperations; Stephen McLoughlin
Staff - EnvironmentGrounds
Subject: [External] RE: Renewal COC Request Follow-up / Contact Change Guidance
Attachments: WCPSS_NCG080026_Owner Affiliation Form.pdf
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
Good morning Ms. Georgoulias,
I have attached the updated and signed `Permit Owner Affiliation Designation Form'. Other updates are listed below by
section. Please contact me if you have any questions. Thank you for your assistance and have a great day.
1. Owner Affiliation: (changes per attached form)
Nathan Slavic, Senior Director
Wake County Public School System, Maintenance and Operations
1551 Rock Quarry Rd. Bldg B
Raleigh, NC 27610
[phone]
[e-mail]
2. Facility Contact Person:
Todd Kneller, Sr. Administrator
Wake County Public School System
1551 Rock Quarry Rd. Bldg B
Raleigh, NC 27610
[phone]
[e-mail]
3. Permit Contact Person
Todd Kneller, Sr. Administrator
Wake County Public School System
1551 Rock Quarry Rd. Bldg B
Raleigh, NC 27610
[phone]
[e-mail]
4. Permit Billing Contact
Steve McLoughlin, Director -Environmental & Grounds
Wake County Public School System
1551 Rock Quarry Rd. Bldg B
Raleigh, NC 27610
[phone]
[e-mail]
Todd A'neller/SeniorAdministrator/Wake Co. Puhlic School System Environmental S Grounds /919--599-3633 ofc
From: Georgoulias, Bethany <[e-mail]>
Sent: Friday, December 10, 2021 9:51 AM
To: Todd Kneller - Staff - EnvironmentGrounds <[e-mail]>

Cc: Carson, Brittany <[e-mail]>
Subject: RE: Renewal COC Request Follow-up / Contact Change Guidance
CAUTION: This email originated from outside of the organization! Proceed with caution!
Good morning,
For your convenience, attached is the Owner Affiliation change form. Instead of submitting it on-line, feel free to email
it to me directly. Please advise the other contact changes that are necessary via email (facility, permit, etc). Be sure to
include mailing addresses, emails, and phone numbers for new contacts.
Best regards,
Bethany Georgoulias (she/her)
Environmental Engineer
Stormwater Program, Division of Energy, Mineral, and Land Resources
N.C. Department of Environmental Quality
919 707 3641 office
[e-mail]
512 N. Salisbury Street, Raleigh, NC 27604 (location)
1612 Mail Service Center, Raleigh, NC 27699-1612 (mailing)
Website: http://deq.nc.gov/about/divisions/energy-mineral-land-resources/stormwater
D, E�
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties
Based on the current guidance to minimize the spread of COVID-19, the Department of Environmental Quality has
adjusted operations to protect the health and safety of the staff and public. Many employees are working remotely or
are on staggered shifts. To accommodate these staffing changes, all DEQ office locations are limiting public access to
appointments only. Please check with the appropriate staff before visiting our offices, as we may be able to handle your
requests by phone or email. We appreciate your patience as we continue to serve the public during this challenging
time.