NCC205669_MODIFICATION Supporting Doc (LEG RESP CHANGE)_20230207

NCG01 Legally Responsible Individual Change Form
Use this form when:
The person who is legally responsible fo.r 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 Stre.et,.6th Floor (Office 640K)
1612 Mail Service .center
Raleigh, I IC 27699-1612
DO NOT MAIL THIS FORM UNTIL YOUR MODIFICATION HAS BEEN REVIEWED AND ACCEPTED AS COMPLETE.
Certificate of Coverage (COC) Number: NCC205669
Name of Project: PNG .Line. 110. MLV-6 Laydown Yi
Legally Responsible Organizational Entity: Piedmont Natural Gas. Company, .LLC
PREVIOUS Legally Responsible Individual: Aaron Weldon
NEW Legally Responsible Individual: Daniel Deese.
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 ($10,0.00)..
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NCGO1 Legally Responsible Individual Change Form
THE FARM YOU MAIL MUSt BI C MPLETEIa WITH AN ORIGIN4L SIGNATURE (NOT DIGITAL} [4D:CFR 122.22•,
Under penalty of law, I certifythat. (check all boxes to indicate.your agreement.):
® I am the person responsible for the construction activities of this project, for satisfying the
requirements of this permit, and forany civil or criminal penalties incurred due to violations of this
permit.
19 1 will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
X, If the approved Erosion and.Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan) of the NCGO10000 General Permit; I WO nonetheless ensure that all conditions of
Part ll of the permit are met on the project at all times.
X] I understand that coverage under this permit will constitute the permit requirementsfor the
discharge(s) and is enforceable In the same manner as an individual permit.
21 This form has been reviewed and is accurate and complete to the best of my knowledge.
Title: ProJect Manager
Mailing Address: 4720 Piedmont Row Drive PNG06A Charlotte, NC 28210
Street Address: Same
Email Address: [e-mail]
Phone Number: 803-731-4246
* IMPORTANT NOTE. This form must: be signed by a responsible corporate officer that owns or operates the
construction activity, suchas a president, secretary, treasurer, or vice president, or a manager that is
authorized in accordance with Part IV, Section B, Item (6) of the NCGOIOOOO permit.
For more. information on signatory requirements; see Part IV, Section B, Item (6) of the NCG610000 permit.
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