NCC192992_Contact Update Request (LEG RESP CHANGE)_20240117

NCG01 Legally Responsible Individual Change Form
Use this form when:
The person who is legally responsible for the permit has changed, but there is NO CHANGE in the project name
or ownership.
**If the project name has changed,or if the ownership of the project has changed,do NOT use this form.**
Instead,you must submit a new NCG01 electronic Notice of Intent(eNOI).
Directions:
Print this form,complete,scan and upload to the Construction Stormwater Permit MODIFICATION Form.
Then, mail the original form to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral& Land Resources Stormwater Program
512 N.Salisbury Street,611 Floor(Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM UNTIL YOUR MODIFICATION HAS BEEN REVIEWED AND ACCEPTED AS COMPLETE,
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE(NOT DIGITAL) [40 CFR 122.22]
Certificate of Coverage(COC) Number: N GC, 01 q 2-
Name of Project: CAI�Ot�t t-jA 7— GATE a- CC+J'S
Legally Responsible Organizational Entity: CAIzp t,1 A, PLA�'ro GIN re— PES
PREVIOUS Legally Responsible Individual: -7-lM LNh9-re-e ] TtAZNI-'I
NEW Legally Responsible Individual: Ilk 1`1 J(—kTZ-N E2
The following section is to be completed and signed by the NEW Legally Responsible Individual.
Per NC General Statute 143-215.6E(i), any person who knowingly makes any false statement, representation,
or certification in any application, record,report,plan, or other document filed or required to be maintained
under this Article or a rule implementing this Article. . . shall be guilty of a Class 2 misdemeanor which may
include a fine not to exceed ten thousand dollars($10,000).
Page 1 of 2

NCG01 Legally Responsible Individual Change Form
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE(NOT DIGITAL) 140 CFR 122.221
Under penalty of law, I certify that(check all boxes to indicate your agreement):
d I am the person responsible for the construction activities of this project,for satisfying the
requirements of this permit, and for any civil or criminal penalties incurred due to violations of this
permit.
d I will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
C� If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCGO10000 General Permit, I will nonetheless ensure that all conditions of
Part II of the permit are met on the project at all times.
dI understand that coverage under this permit will constitute the permit requirements for the
discharge(s) and is enforceable in the same manner as an individual permit.
Ii This form has been reviewed and is accurate and complete to the best of my knowledge.
*Signature: Date: 0 2-02
Print Name of Signed: t
Title: �lZ�S1j��NT & CQ
Mailing Address: �{UN' �5 V 1 1.1. I SC, 7—SO-7 0
Street Address: (D o O c) S A"tA p F—r-> .
Email Address: (!` ck+Zln C-,.— 0 G0.lr O t l v-1 yn��V-. O
Phone Number: N t- (_O(o -- (LP S 3
*IMPORTANT NOTE: 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 1V,Section B, Item(6)of the NCG010000 permit.
For more information on signatory requirements,see Part IV,Section B, Item (6)of the NCGO10000 permit.
Page 2 of 2

Georgoulias, Bethany
From: Erin Katzner <[e-mail]>
Sent: Wednesday, January 17, 2024 11:25 AM
To: Georgoulias, Bethany; Tran, Kieu M; Holloman, Tevye L
Subject: Re: [External] Re: Notice of Deficiency: Unpaid Permit Fee for NCC192992 - Contact
Update
Attachments: Stormwater Permit Contact Change Form.pdf
CAUTION: External email. Do not click links or open attachments unless verified. Report suspicious emails with the Report Message
button located on your Outlook menu bar on the Home tab.
I am so sorry! Here's the completed one.
Thank you!
Erin
From: Georgoulias, Bethany<[e-mail]>
Sent:Wednesday,January 17, 2024 11:22 AM
To: Erin Katzner<[e-mail]>;Tran, Kieu M <[e-mail]>; Holloman,Tevye L
<[e-mail]>
Subject: RE: [External] Re: Notice of Deficiency: Unpaid Permit Fee for NCC192992-Contact Update
I
You don't often get email from [e-mail] why this is important
WARNING: This email originated outside of Carolina Raptor Center. Do not click links or open attachments unless you recognize the
sender and know the content is safe.
Hi! I think you uploaded the blank form by accident?
Bethany Georgoulias(she/her)
Environmental Engineer,Stormwater Program
DEMLR Laserfiche Administrator
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/stormwatgr
From: Erin Katzner<[e-mail]>
Sent:Wednesday,January 17, 2024 11:14 AM
To: Georgoulias, Bethany<[e-mail]>;Tran, Kieu M <[e-mail]>; Holloman,Tevye
L<[e-mail]>
Subject: [External] Re: Notice of Deficiency: Unpaid Permit Fee for NCC192992-Contact Update
1

CAUTION: External email. Do not click links or open attachments unless verified. Report suspicious emails with the Report Message
button located on your Outlook menu bar on the Home tab.
Hi Bethany,
Thank you so much for your help! I have attached the completed, signed, and scanned
form to this email and will get the original in today's mail.
Thank you again and I hope you have a great remainder of your week!
Erin
Erin Katzner
President&CEO
Carolina Raptor Center I Learn. Play. Explore.
6000 Sample Road I Huntersville, NC 28078
Direct: [phone] x 120
Cell:[phone]
Email:[e-mail]
Pronouns: she, her, hers
Connect:www.carolinaraptorcenter.org I www.thisisquest.org I Instagram I Facebook I Twitter I YouTube
DVA
Tel
M
RA PTO R
CENTER-
From: Georgoulias, Bethany<[e-mail]>
Sent:Wednesday,January 17, 2024 10:10 AM
To: Erin Katzner<[e-mail]>;Tran, Kieu M <[e-mail]>; Holloman,Tevye L
<[e-mail]>
Subject: RE: Notice of Deficiency: Unpaid Permit Fee for NCC192992-Contact Update
You don't often get email from bethany_.georgouliasOdeq.nc.gov.Learn why this is important
WARNING: This email originated outside of Carolina Raptor Center. Do not click links or open attachments unless you recognize the
sender and know the content is safe.
Good morning, Erin,
Thank you for reaching out about this change. To change the legally responsible person for the permit(currently listed
as Jim Warren), please complete that attached form. You can scan it and email it back to me, but we also need the hard
copy with original signature mailed back to us (EPA requirements) at the address noted.
Thanks so much,
2

Bethany Georgoulias (she/her)
Environmental Engineer, Stormwater Program
DEMLR Laserfiche Administrator
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
From: Erin Katzner<[e-mail]>
Sent:Tuesday,January 16, 2024 2:44 PM
To:Tran, Kieu M <[e-mail]>; Georgoulias, Bethany<[e-mail]>; Holloman,Tevye
L<[e-mail]>
Subject: [External] Re: [External]Notice of Deficiency: Unpaid Permit Fee for NCC192992
CAUTION: External email. Do not click links or open attachments unless verified. Report suspicious emails with the Report Message
button located on your Outlook menu bar on the Home tab.
Hi Kieu, Bethany, and Tev,
I am the new CEO of the Carolina Raptor Center and need to have our permit information
(see below) updated to my email address and other contact information so that I can
provide more timely payments for our permit. Communications are currently being sent to
our previous Executive Director's, Jim Warren's, email address and unfortunately Jim passed
away two years ago.
Please let me know what I should do to update this information and thank you in
advance for your help!
Erin
Erin Katzner
President&CEO
Carolina Raptor Center I Learn. Play. Explore.
6000 Sample Road I Huntersville, NC 28078
Direct: [phone] x 120
Cell: [phone]
Email:[e-mail]
Pronouns: she, her, hers
Connect:www.carolinaraptorcenter.org I www.thisisquest.org I Instagram I Facebook I Twitter I YouTube
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RA PTO R
CENTER_
From: Matthews, Christopher<Christopher.Matthews@ mecklenburgcountync.gov>
Sent:Tuesday,January 16, 2024 11:53 AM
To: Erin Katzner<[e-mail]>
Cc: Sweat, Steven <[e-mail]>; [e-mail]<[e-mail]>;
[e-mail]<[e-mail]>;[e-mail]
<[e-mail]>; [e-mail]<[e-mail]>
Subject: FW: [External]Notice of Deficiency: Unpaid Permit Fee for NCC192992
You don't often get email from chri stop her.matthews0mecklenburgcountync.gov.Learn why this is important
WARNING: This email originated outside of Carolina Raptor Center. Do not click links or open attachments unless you recognize the
sender and know the content is safe.
Erin,
Please see below and attached.
Your immediate attention to this is appreciated. Also, please provide the State with your
updated contact information so this can be taken care of in a timely fashion.
Chris Matthews
Division Director
Park and Recreation I Nature Preserves and Natural Resources
Mecklenburg County Government
W:980-314-1019 1 M:980-722-2404 1 ParkAndRec.MeckNC.Gov
RE 11111D®N®
From: Sweat, Steven <[e-mail]>
Sent:Tuesday,January 16, 2024 10:29 AM
To: Matthews, Christopher<[e-mail]>
Subject: FW: [External]Notice of Deficiency: Unpaid Permit Fee for NCC192992
FYI
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Steven Sweat,AIA I LEED AP
Senior Project Manager
Asset and Facility Management I Design&Construction
Mecklenburg County Government
t 980-314-2521 1 m 704-589-7748 1 MeckNC.Gov
�On
From: [e-mail]<[e-mail]>
Sent:Tuesday,January 16, 2024 1:33 AM
To: Iwa rren @ca rol i na ra ptorcenter.org
Cc: [e-mail]; [e-mail];[e-mail]; Sweat, Steven
<[e-mail]>
Subject: [External]Notice of Deficiency: Unpaid Permit Fee for NCC192992
CAUTION:This email originated from outside of the organization. Do not click links or open attachments unless you
recognize the sender and know the content is safe.
This email is to convey a Notice of Deficiency for failure to pay the 2023 annual permit fee per the requirements of NC
General Statute 143-215.3D(a)(4). Please be sure to coordinate payment with other parties copied on this e-mail to avoid
duplicate payments.
Your Certificate of Coverage (COC) under the Construction Stormwater NPDES General Permit was not renewed because
the annual fee payment(Invoice No. NCC192992-2023)was not received. The payment is 15 day(s) overdue. A Notice of
Deficiency is attached.
Please contact the Stormwater Program at [e-mail] or(919) 707-3649. Please reference:
COC no. NCC192992
This COC is for Carolina Raptor Center in Mecklenburg County, issued to Carolina Raptor Center.
Annual fee payment can be made through this website:
https://deg.nc.gov/sw-epayments
If this project has been closed-out or sold,it is important that you submit a Notice of Termination request here:
https://edocs.deg.nc.gov/Forms/NCGOI-Termination
Please visit https://deg.nc.gov/NCG01 for more information about this permit.
The NC DEMLR Stormwater Program
512 N. Salisbury Street, Archdale Building 6th Floor, 1612 Mail Service Center, Raleigh, NC 27699-1612
This email was automatically generated by Laserfiche. Please do not respond to this email address, as responses are not
monitored.
Email correspondence to and from this address may be subject to the North Carolina Public Records Law and may be disclosed to third parties by an authorized
state official.
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