NCG130027_Permit Contact Update Request_20230731

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by Anonymous User 7/31/2023 9:57:42 AM (Permit Contact Update Request)
Approve by Joyce Sanford 9/5/2023 12:48:41 PM (Contact Update Review)
• The task was assigned to DEMLR SW Admin General.The due date is: September 11,2023 5:00 PM
7/31/2023 9:57:47 AM
• The task was assigned to Joyce Sanford by round robin distribution 7/31/2023 9:57:48 AM

DEQIwo NPDES Stormwater -Request
Request Submitted
NPDES Permit Enter your NPDES stormwater permit number or Certificate of Coverage(COC)number.
Number* NCG130027
Begins with NCS,NCG,or NCGNE(no exposure)
Facility Name* Safety Kleen Corp-Randolph
(Used to verify permit number)
Check permit contact information for your permit by running a Stormwater Permit Summary Report.
Guidance for COC holders: Do not enter the General Permit number with all 0's(for example, NCG030000)but instead
your Certificate of Coverge(COC)number.
Check all that Owner Affiliation(Legally Responsible Individual)Update
*
apply: Permit Ownership Transfer or Facility Name Change
Delegation of Signature Authority(DOSA)
Permit Contact Update
Billing Contact Update
Facility Contact Update
Other Contact Update
Permit Contact Update
Provide new permit contact information
This person should REPLACE the current permit contact.
This person should just be added as another permit contact.
New Contact Name* First and Last Name
Todd Blake
E-mail Address* [e-mail]
Phone No.* 3366440332
Mailing Address* PO Box 843 Oak Ridge, NC 27310
Physical Address If different than mailing address
6182 Old Mendenhall Road
Archdale, NC 27263
Add another permit contact if needed by clicking the'Add'button below
Facility Contact Update
Provide new facility contact information
This person should REPLACE the current facility contact.
This person should just be added as another facility contact.
New Contact Name* First and Last Name
Andrew Tilley

E-mail Address* [e-mail]
Phone No.* 3362898257
Mailing Address* 6182 Old Mendenhall Road
Archdale, NC 27263
Physical Address If different than mailing address
Add another facility contact if needed by clicking the'Add'button below
Submitter's Name* Please enter your FIRST and LAST name
Todd Blake
Phone Number* Please enter your phone number
3366440332
Any format is fine.
Email Address* Please enter a valid e-mail address
[e-mail]
A confirmation of submission will be e-mailed to this address.
* By checking the box and signing below, I certify that:
I have given true,accurate,and complete information on this form;
I agree that submission of this form is a"transaction"subject to Chapter 66,Article 40 of the NC General Statutes(the
"Uniform Electronic Transactions Act");
I agree to conduct this transaction by electronic means pursuant to Chapter 66,Article 40 of the NC General Statutes(the
"Uniform Electronic Transactions Act");
I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written
signature(except for any uploaded Owner Affiliation Change or Delegation of Signature of Authority forms,which
also must be mailed in with original signature);AND
I intend to electronically sign and submit this Permit Contact Update Request form.
Signature
6Jo���W- ff/k r
Date 7/31/2023
Questions? Contact [e-mail].

Review
Verify Permit No.* Revise permit number below if incorrect.
NCG 130027