NCC202331_Contact Update Request (Leg Resp and Site Contact)_20221024

NCG41 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 (eNOl).
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, 61h 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 CC Zo Z 3 3 i
Name of Project: iLMo S N E-APnAA&-x R Lc) t-
Legally Responsible Organizational Entity: NNA<> lC0— SCltiNr.frl C.
PREVIOUS Legally Responsible Individual: Q tQ1DOti L,,d % L Lt RrA So rN
NEW Legally Responsible Individual: (--AflelM 13E L.L
The following section is to be completed and signed by the NEW Legally Responsible Individual.
Per NC General Statute 143-215.6B (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 122.22]
Under penalty of law, I certify that (check all boxes to indicate your agreement):
C� 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.
L� I will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
!� If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the MCGO10000 General Permit, I will nonetheless ensure that all conditions of
/ Part II of the permit are met on the project at all times.
L� I 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.
Q" This form has been reviewed and is accurate and complete to the best of my knowledge.
ature:
Print Name of Signed: j--� DFr M
(V\?9 Z l
Date: Z/ o c r 2 a2 "L
Title: 512 •_._ I�,Ar� %('�E �R'S C Z` �N G �J�-� N
Mailing Address: 900 &AA&T-1 Llrhe& J<--G J 12 w C,,,Ltr A)C3
2 r
Street Address: - 00 _WVA.) J o rh� lE,A,& JR w%? _ CoAtN--J, c LC Ak Z 7$3'
Email Address: t 1. M EU- TN ' 2Mo I S HF(-. ca ►�
Phone Number: 2 51 - q 07 - 0-7 Z
* 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 IV, Section B, Item (6) of the NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCG010000 permit.
Page 2 of 2

Georgoulias, Bethany
From: Campbell, Adam <[e-mail]>
Sent: Friday, October 21, 2022 12:42 PM
To: Georgoulias, Bethany
Subject: [External] RE: Construction SW General Permit Annual Fee Resolved - NCC202331
Attachments: Scanned from a Xerox Multifunction Printer.pdf
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
Please find attached the scanned form. The form has been put into the mail.
Kind regards,
Adam Campbell, PE
Sr Manager — Project Engineering
Pharma Services
Patheon, a part of Thermo Fisher Scientific
5900 Martin Luther King Jr Hwy I Greenville, NC 27834 USA
Tel: [phone]
adam.campbell(cathermofisher.com I thermofisher.com/Patheon
From: Georgoulias, Bethany <[e-mail]>
Sent: Thursday, October 6, 2022 7:54 AM
To: Campbell, Adam <[e-mail]>
Subject: RE: Construction SW General Permit Annual Fee Resolved - NCC202331
Importance: High
CAUTION: This email originated from outside of Thermo Fisher Scientific. If you believe it to be suspicious, report using the Report
Phish button in Outlook or send to [e-mail].
Good morning,
I'm following up on this because we have not received this form yet. We cannot update the legally responsible person
on this construction stormwater permit without it. Your action is needed so that future correspondence does not keep
going to Mr. Williamson.
Please let us know if you have any questions!
Thank you,
Bethany Georgoulias
From: Georgoulias, Bethany
Sent: Wednesday, September 21, 2022 7:11 AM
To:'Williamson, Brandon' <brandon.wiIlia [e-mail]>
Cc:'Campbell, Adam' <[e-mail]>
Subject: RE: Construction SW General Permit Annual Fee Resolved - NCC202331
Importance: High

Good morning,
I am just following upon this. Please send us the completed change form when you can so we can update the legally
responsible individual for this stormwater permit and prevent future correspondence from going to the wrong
person. Thank you!
From: Georgoulias, Bethany
Sent: Thursday, September 15, 2022 3:54 PM
To: Williamson, Brandon <[e-mail]>; Tran, Kieu M <[e-mail]>
Cc: Campbell, Adam <[e-mail]>
Subject: RE: Construction SW General Permit Annual Fee Resolved - NCC202331
Importance: High
Good afternoon,
We appreciate notice of this change. Because you are designated as the legally responsible person for this permit, Adam
will need to complete and sign the attached form in order to change that designation. A scanned copy can be emailed
back to me, but the original signed copy must be sent in to our office per the instructions on the form. Then we can
update the contact information for this permit.
B. Permittee information
Part B.
P&wb a tiom-lino - Lx;* Faapxnble Bvty sd Ytii &tal
Important The person rho signs the NU Gerffwafion Farm and s,igm the CenKcation in Section 1= of this applicatiarn
font should be the same person as IIsted in THIS SECTION. or an authorized responsible individual vAthin the s_arr
orgarrimtion- Thel pamn rnust be a responsible Corporate Officer uho oums or operales the owstrUdiori acWlty, such
as a president, secretary, treasurer, or vice president, or a manager that is authorized in accordance with Parl IV,
Section B, ltem (6) of the NCG010000 General Permit. For more information on signatory requirerwrtts, sto Part
IV, Section & Ito m(e) of that permit.
1.Organization Le9alY Fbsr— bL,BUs
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2. First NamE * Brandon
I Gapotauon erWf FAgEiered Ageru Fr9t Nhnp
3. fast Name" Mliarn&cm
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3b, Title Project Engineer
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
ki;
DE
NORTH CAROLINA -
Department of Environmental Quality
Email correspondence to and from this address is subject to the North
Carolina Public Records Law and may be disclosed to third parties.
From: Williamson, Brandon <[e-mail]>
Sent: Thursday, September 15, 2022 3:29 PM
To: Tran, Kieu M <[e-mail]>; Georgoulias, Bethany<[e-mail]>
Cc: Campbell, Adam <[e-mail]>
Subject: [External] RE: Construction SW General Permit Annual Fee Resolved - NCC202331
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
Afternoon,
Moving forward please change my responsibility to Adam Campbell.
Adam Campbell, PE
Sr Manager — Project Engineering
Pharma Services
Patheon, a part of Thermo Fisher Scientific
5900 Martin Luther King Jr Hwy I Greenville, NC 27834 USA
Tel: [phone]
adam.campbella-thermofisher.com I thermofisher.com/Patheon
Brandon Williamson
Sr. Project Engineer
Pharma Services
Thermo Fisher Scientific
5900 Martin Luther King Jr Highway I Greenville, NC 27834 USA
P: [phone] 1 C: [phone]
[e-mail] I www.thermofisher.com/patheon
Thermo Rsh r
I E N T I F I
The world leader in serving science

From: [e-mail] <[e-mail]>
Sent: Monday, August 1, 2022 8:53 AM
To: Williamson, Brandon <[e-mail]>
Cc: [e-mail]; [e-mail]; Williamson, Brandon
<[e-mail]>
Subject: Construction SW General Permit Annual Fee Resolved - NCC202331
CAUTION: This email originated from outside of Thermo Fisher Scientific. If you believe it to be suspicious, report using the Report
Phish button in Outlook or send to [e-mail].
Dear Construction General Permit Permittee:
This email is to notify you that the 2022 annual fee for Certificate of Coverage (COC) no. NCC202331 has been
resolved. If the permit remains active, it has been successfully renewed. If the permit is no longer active, no future fees
will be required.
This COC is for ThermoFisher Temporary Parking Lot in Pitt County, issued to ThermoFisher Scientific. This
communication is in reference to Invoice no. NCC202331-2022.
If you have any questions, please contact the Stormwater Program at [phone], or visit https://deg.nc.gov/NCG01.
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.