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HomeMy WebLinkAboutNCG020881_Permit Contact Update Request_20230502 Action History (UTC-05:00)Eastern Time(US&Canada) Submit by Anonymous User 5/2/2023 10:17:58 AM (Permit Contact Update Request) Approve by Joyce Sanford 5/19/2023 10:17:57 AM(Contact Update Review) • The task was assigned to DEMLR SW Admin General.The due date is:June 13,2023 5:00 PM 5/2/2023 10:18:03 AM • The task was assigned to Joyce Sanford by round robin distribution 5/2/2023 10:18:03 AM DEQIwo NPDES Stormwater -Request Request Submitted NPDES Permit Enter your NPDES stormwater permit number or Certificate of Coverage(COC)number. Number* NCG020881 Begins with NCS,NCG,or NCGNE(no exposure) Facility Name* Brickhaven No.2 Mine Tract B (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 Person(s) with Delegation of Signature Authority (DOSA) Delegation of Please upload the signed"Stormwater Permit Delegation of Signature Authority Form" Signature Authority NC DOSA Form General Shale Brick-Moncure.pdf 567.31 KB 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 Larry Cockerill E-mail Address* larry.cockerill@generalshale.com Phone No.* 9197746533 Mailing Address* 300 Brick Plant Road Moncure, NC 27559 Physical Address If different than mailing address 1500 Moncure Flatwood Rd Moncure, NC 27559 Add another facility contact if needed by clicking the'Add'button below Submitter's Name* Please enter your FIRST and LAST name Steve Wyse Phone Number* Please enter your phone number 4232824661 Any format is fine. Email Address* Please enter a valid e-mail address steve.wyse@generalshale.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 5 W wc/-4s Date 5/2/2023 Questions? Contact bethany.georgoulias@ncdenr.gov. Review Verify Permit No.* Revise permit number below if incorrect. NCG020881