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HomeMy WebLinkAboutNCG110150_Permit Contact Update Request_20230427 Action History (UTC-05:00)Eastern Time(US&Canada) Submit by Anonymous User 4/27/2023 2:02:58 PM (Permit Contact Update Request) Approve by Joyce Sanford 5/11/2023 3:17:53 PM(Contact Update Review) • The task was assigned to DEMLR SW Admin General.The due date is:June 8,2023 5:00 PM 4/27/2023 2:03:03 PM • The task was assigned to Joyce Sanford by round robin distribution 4/27/2023 2:03:03 PM pEQNPDES Stormwater Permit Contact Update Request Request Submitted NPDES Permit Enter your NPDES stormwater permit number or Certificate of Coverage(COC)number. Number* NCG110150 Begins with NCS,NCG,or NCGNE(no exposure) Facility Name* Wallace Regional WWTP (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 J Owner Affiliation(Legally Responsible Individual)Update * apply: ❑ Permit Ownership Transfer or Facility Name Change Q Delegation of Signature Authority(DOSA) ❑ Permit Contact Update Q Billing Contact Update ❑ Facility Contact Update Tj Other Contact Update 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 Joseph Trollinger E-mail Address* jrollinger@wallacenc.gov Phone No.* 910-285-4136 Mailing Address* 316 E. Murray St Wallace INC 28466 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 signature authority for Inyoung Seo.pdf 154.14KB pdf only Other Contact Updates Only use this section if none of the categories above apply. Provide details about Owner Contact Person-remove Laurence Bergman's information and replace with another contact Robert Taylor,Jr,Town manager, rtaylor@wallacenc.gov,910-285-4136 update:* Submitter's Name* Please enter your FIRST and LAST name Lisa Cottle Phone Number* Please enter your phone number 910-665-2091 Any format is fine. Email Address* Please enter a valid e-mail address Icottle@wallacenc.gov 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 4/27/2023 Questions? Contact bethany.georgoulias@ncdenr.gov. Review Verify Permit No.* Revise permit number below if incorrect. NCG110150