NCC205162_Contact Update Request (Legally Resp Change)_20221212

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, 6`h 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: NCC205162
Name of Project: Affordable Suites Hotel - Statesville Road
Legally Responsible Organizational Entity: LG APT Charlotte Northlake LP
PREVIOUS Legally Responsible Individual: Don Keum
NEW Legally Responsible Individual: Bruce Collins
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) [40 CFR 122.22]
Under penalty of law, I certify that (check all boxes to indicate your agreement):
® 1 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.
® I will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
�4 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.
® 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.
V This form has been reviewed and is accurate and complete to the best of my knowledge.
*Signature: Date:12/12/2022
Print Name of Signed: Bruce Collins
Title: Executive Vice President of Construction
Mailing Address: 10801 Monroe Road. Suite 200. Matthews. NC 28105
Street Address: 9655 Statesville Road, Charlotte, NC 28269
Email Address: [e-mail]; [e-mail]
Phone Number: 704-879-2849
* 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 NCGO10000 permit.
Page 2 of 2

Georgoulias, Bethany
From: Latwanna Jenkins <[e-mail]>
Sent: Monday, December 12, 2022 3:57 PM
To: Georgoulias, Bethany; Holloman, Tevye L
Cc: Bruce Collins
Subject: RE: [External] RE: Construction Stormwater Permit Annual Fee - NCC205162
Attachments: C0108 Northlake_stayAPT Suites - Change in Responsible Party.pdf
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
Bethany,
Thank you for your assistance with this. Here is a copy of the form. The physical copy will be in the mail today and should
be received by the end of the week.
Kind Regards,
Latwanna Jenkins
Real Estate and Construction
Administrator
AS Manager LLC
1o8o1 Monroe Road, Suite 200
Matthews, NC 281o5
O: 704.702.6 �,�
E: lien kinsna stavaot.com
stayapt.com
stay
,apt
From: Georgoulias, Bethany <[e-mail]>
Sent: Monday, December 5, 2022 7:54 PM
To: Latwanna Jenkins <[e-mail]>; Holloman, Tevye L <[e-mail]>
Cc: Bruce Collins <[e-mail]>
Subject: RE: [External] RE: Construction Stormwater Permit Annual Fee - NCC205162
Importance: High
Good evening,
The [e-mail] is an unmonitored email address, so thank you for reaching out to other staff.
If there has been a change in legally responsible person for this permit, we need the attached form completed and
signed to make that change. You can email me a copy, but a hard copy must be mailed back to us at the address on the
form for EPA requirements. Don Keum is listed as the legally responsible person, so this is a necessary action for us to
make the change.
Thankyou!
Bethany Georgoulias (she/her)
1

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
cc. ��� DE
NORTH CAROLINA
Department of Environmental Duality
Email correspondence to and from this address is subject to the North
Carolina Public Records Law and may be disclosed to third parties.
From: Latwanna Jenkins <[e-mail]>
Sent: Monday, December 5, 2022 5:06 PM
To: [e-mail]; Georgoulias, Bethany<[e-mail]>; Holloman, Tevye L
<[e-mail]>
Cc: Bruce Collins <[e-mail]>
Subject: [External] RE: Construction Stormwater Permit Annual Fee - NCC205162
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
To Whom It May Concern:
I am checking in to ensure that our contact for the company has been changed in your system. Could you please confirm
all correspondence moving forward will go to Bruce Collins at [e-mail] instead of Don Keum?
Thank you,
Latwanna Jenkins
Real Estate and Construction
Administrator
AS Manager LLC
10801 Monroe Road, Suite 200
Matthews, NC 28105
O: 704.702.6'i'i7
E: lienkinsna stavaot.com
stayapt.com
From: Latwanna Jenkins
stay
apt'"
UITES
Sent: Thursday, December 1, 2022 9:16 AM
To: [e-mail]
Cc: Bruce Collins <[e-mail]>
Subject: RE: Construction Stormwater Permit Annual Fee - NCC205162

Good Morning,
Could you please change the contact from Don Keum to Bruce Collins at bcollins ostayapt.com?
Thank you,
Latwanna Jenkins
Real Estate and Construction
Administrator
AS Manager LLC
10801 Monroe Road, Suite 200
Matthews, NC 28105
O: 704.702.6,1-,1
E: Lien kinscastavaat.com
staya pt.com
stay
apt-
, UITES
From: [e-mail] <[e-mail]>
Sent: Thursday, December 1, 2022 8:33:45 AM
To: Don Keum <[e-mail]>
Cc: Morgan Donohue <[e-mail]>; [e-mail]
<[e-mail]>; [e-mail] <[e-mail]>
Subject: Construction Stormwater Permit Annual Fee - NCC205162
Attached is the 2022 annual fee invoice for your Construction Stormwater NPDES permit, COC no.
NCC205162. When using the ePayment website, be sure to enter ONLY the COC permit number (not the
invoice number with "-2022" after it). Please contact Tev Holloman at [e-mail] or Danny
Smith at [e-mail] with any questions.
If this project has been closed out, you must submit a Notice of Termination (NOT) request here:
hnps://edocs.deq.nc.gov/Forms/NCGO 1-Termination
Sincerely,
The DEMLR Stormwater Program
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