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HomeMy WebLinkAboutNCG060205_Permit Contact Update Request_20230130Action History (UTC-05:00) Eastern Time (US & Canada) Submit by Anonymous User 1/30/2023 4:16:53 PM (Permit Contact Update Request) Approve by Joyce Sanford 4/4/2023 10:30:38 AM (Contact Update Review) • The task was assigned to DEMLR SW Admin General. The due date is: March 13, 2023 5:00 PM 1/30/2023 4:17:02 PM • The task was assigned to Kieu Tran by round robin distribution 1/30/2023 4:17:02 PM • Kieu Tran reassigned the task to Joyce Sanford 3/23/2023 3:18:40 PM Request Submitted NPDES Permit Enter your NPDES stormwater permit number or Certificate of Coverage (COC) number. Number* NCG060205 Begins with NCS, NCG, or NCGNE (no exposure) Facility Name* Custom Finishers, Inc. (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 Permit Contact Update Provide new permit contact information This person should REPLACE the current permit contact. This person should just be added as another permit contact. New Contact Name* First and Last Name Christopher Wilkins E-mail Address* cwilkins@customfinishers.com Phone No.* 3364317141 Mailing Address* 2213 Shore St High Point, NC 27263 Physical Address If different than mailing address This person should REPLACE the current permit contact. This person should just be added as another permit contact. New Contact Name* First and Last Name Dennis Dzielski E-mail Address* cfidennis@aol.com Phone No.* 3364317141 Mailing Address* 2213 Shore Street High Point, NC 27263 Physical Address If different than mailing address Add another permit contact if needed by clicking the 'Add' button below Stormwater Program's Billing Specialist will be notified about the billing update request by email upon approval. Billing Contact Update Provide new billing contact information Note: This person will REPLACE the current billing contact. We can only designate one billing contact in our permitting database. New Contact Name* First and Last Name Sylvia Hicks E-mail Address* shicks@customfinishers.com Phone No.* 3364317141 Mailing Address* 2213 Shore St High Point, NC 27263 Physical Address If different than mailing address Person(s) with Delegation of Signature Authority (DOSA) Delegation of Please upload the signed "Stormwater Permit Delegation of Signature Authority Form" Signature Authority SW 4.pdf 1.05MB pdf only Facility Contact Update Provide new facility contact information *+ This person should REPLACE the current facility contact. This person should just be added as another facility contact. New Contact Name* First and Last Name Christopher Wilkins E-mail Address* cwilkins@customfinishers.com Phone No.* 336-431-7141 Mailing Address* 2213 Shore St High Point, NC 27262 Physical Address If different than mailing address This person should REPLACE the current facility contact. This person should just be added as another facility contact. New Contact Name* First and Last Name Dennis Dzielski E-mail Address* cfidennis@aol.com Phone No.* 3364317141 Mailing Address* 2213 Shore Street Physical Address If different than mailing address Add another facility contact if needed by clicking the 'Add' button below Submitter's Name* Please enter your FIRST and LAST name Dennis Dzielski Phone Number* Please enter your phone number 336-431-7141 Any format is fine. Email Address* Please enter a valid e-mail address cfidennis@aol.com 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 Date 1 /30/2023 Questions? Contact bethany.georgoulias@ncdenr.gov. Review Verify Permit No.* Revise permit number below if incorrect. NCG060205