NCS000446_Permit Contact Update Request_20220601

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 6/1/2022 9:59:27 AM (Permit Contact Update Request)
Approve by Tran, Kieu M 6/2/2022 8:07:34 AM (Contact Update Review)
• The task was assigned to Tran, Kieu M. The due date is: July 13, 2022 5:00 PM 6/1/2022 9:59 AM

Request Submitted
NPDES Permit Enter your NPDES stormwater permit number or Certificate of Coverage (COC) number.
Number* NCS000446
Begins with NCS, NCG, or NCGNE (no exposure)
Facility Name* Town of Apex
(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
Other Contact Updates
Only use this section if none of the categories above apply.
Provide details about Owner Contact Person(s) needs to be updated as follows:
another contact
update: * Jose Martinez (REMOVE - left the Town)
Stan Fortier (REMOVE - retired)
Drew Havens (REMOVE - left the Town)
David Hughes (REMOVE - retired)
PLEASE ADD - Robert Patterson (same address, phone: [phone],
[e-mail])
Please also remove David Hughes from the DOSA list - keeping Mike Deaton is fine.
Thank you!
Submitter's Name* Please enter your FIRST and LAST name
Jessica Bolin
Phone Number* Please enter your phone number
919-249-3537
Any format is fine.
Email Address* Please enter a valid e-mail address
jessica. [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
Cdd+ C A6A
Date 6/1 /2022
Questions? Contact [e-mail].

Review
Verify Permit No.* Revise permit number below if incorrect.
NCS000446