NCC222064_Contact Update Request (Leg Resp Change)_20230530

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, 61^ 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: !J G C. aI 1 A O Co 4
Name of Project: Oak V Ic.w S'A-er c;4!
Legally Responsible Organizational Entity: O ,Jk J in,,1 s),_ 5; w C,, }y LLC
PREVIOUS Legally Responsible Individual: Se- M" Q.F. L,e,,"r (-r Ct,
NEW Legally Responsible Individual: At4xt6 tS'4J-x4-'&
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 ($10,000).
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 122.221
Under penalty of law, I certify that (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 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
r Sediment Control Plan.
1# 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.
This form has been reviewed and is accurate and complete to the best of my knowledge.
Title: 5 V i c..c- prc-s i L-�
Mailing Address: 160 w, Mw SL. -66"�'
Lon �,_a ��isoziON ftas
Street Address: ��
Email Address:
Phone Number: (e 14 - S S a _ 51 a 8
*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 NCG010000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCG010000 permit.
Page 2 of 2

Georgoulias, Bethany
From: Jacob Gill <[e-mail]>
Sent: Tuesday, May 30, 2023 12:58 PM
To: Georgoulias, Bethany; Randy A. Purol
Cc: Holloman, Tevye L; Alexis Dunfee
Subject: RE: [External] Certificate of Coverage Renewal
Attachments: NCG01 Legally Responsible Individual Change Form.pdf
Follow Up Flag:
Flag Status:
Follow up
Flagged
CAUTION: External email. Do not click links or open attachments unless verified. Report suspicious emails with the Report Message
button located on your Outlook menu bar on the Home tab.
Bethany —
Updated form is attached. Because of the ownership structure, I had our SVP of Development Alexis Dunfee sign it. She
will be the legally responsible person. If possible, please keep me as the contact in the system or at least CC me on
correspondence as I am the project manager.
Once accepted, I will mail the original copy to the DEMLR office in Raleigh.
Thanks again!
Jake
Jake Gill I Development Manager
0
p: 865.607.1668 1 160 West Main Street, Suite 200, New Albany, OH 43054
From: Georgoulias, Bethany
Sent: Tuesday, May 30, 2023 12:15 PM
To: Jacob Gill; Randy A. Purol
Cc: Holloman, Tevve L
Subject: RE: [External] Certificate of Coverage Renewal
Hi, Jacob,
All the records for this permit are available in our repository. Here's a link to the NCC222064 folder. The Certificate of
Coverage is in there.
Best,
Bethany Georgoulias (she/her)

Environmental Engineer, Stormwater Program
DEMLR Laserfiche Administrator
Division of Energy, Mineral, and Land Resources
N.C. Department of Environmental Quality
919 707 3641 office
[e-mail]
DEQ is updating its email addresses to @deq.nc.gov in phases from May 1st to June 9th. Employee email addresses
may look different, but email performance will not be impacted.
S12 N. Salisbury Street, Raleigh, NC 27604 (location)
1612 Mail Service Center, Raleigh, NC 27699-1612 (mailing)
Website: httl2://deq.nc.gov/about/divisions/energy-mineral-land-resources/stormwatgr
From: Jacob Gill <[e-mail]>
Sent: Tuesday, May 30, 2023 12:13 PM
To: Georgoulias, Bethany<[e-mail]>; Randy A. Purol <[e-mail]>
Cc: Holloman, Tevye L <[e-mail]>
Subject: RE: [External] Certificate of Coverage Renewal
CAUTION: External email. Do not click links or open attachments unless verified. Report suspicious emails with the Report Message
button located on your Outlook menu bar on the Home tab.
Good afternoon Bethany —
Hope you had a great holiday weekend!
Could you send me the copy of the old Certificate of Coverage? I want to make sure we fill it out correctly.
Thanks,
Jake
Jake Gill I Development Manager
p 865.607.1668 1 160 West Main Street, Suite 200, New Albany, OH 43054
From: Georgoulias, Bethany
Sent: Friday, May 26, 2023 11:35 AM
To: Jacob Gill; Randy A. Purol
Cc: Holloman, Tevye L
Subject: RE: [External] Certificate of Coverage Renewal
No problem. I'll update at least the billing contact with your email before those invoices run.
Bethany Georgoulias (she/her)
Environmental Engineer, Stormwater Program

DEMLR Laserfiche Administrator
Division of Energy, Mineral, and Land Resources
N.C. Department of Environmental Quality
919 707 3641 office
[e-mail]
DEQ is updating its email addresses to @deq.nc.gov in phases from May 1st to June 9th. Employee email addresses
may look different, but email performance will not be impacted.
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
From: Jacob Gill <[e-mail]>
Sent: Friday, May 26, 2023 10:51 AM
To: Georgoulias, Bethany<[e-mail]>; Randy A. Purol <[e-mail]>
Cc: Holloman, Tevye L <[e-mail]>
Subject: RE: [External] Certificate of Coverage Renewal
CAUTION: External email. Do not click links or open attachments unless verified. Report suspicious emails with the Report Message
button located on your Outlook menu bar on the Home tab.
Hi Bethany —
I will work to have this complete next week. I am travelling today. As long as I get the email for the upcoming payment,
we should be good for now. I just do not want that to slip.
Thanks,
Jake
Jake Gill I Development Manager
0
p: 865.607.1668 1 160 West Main Street, Suite 200, New Albany, OH 43054
From: Georgoulias, Bethany
Sent: Friday, May 26, 2023 10:07 AM
To: Jacob Gill; Randy A. Purol
Cc: Holloman, Tevye L
Subject: RE: [External] Certificate of Coverage Renewal
Some people who received this message don't often get email from bethany [e-mail]. Learn why this is
important
Hi, Jake,
Since Jennifer was listed as Legally Responsible Person, we need you to fill out the attached form. You can scan it and
send it to me so I can start the updates, but be sure to mail the original (EPA requirement).

If you can get it back to me today, I can make the updates ahead of the invoices getting created by our system —
otherwise we can do them next week, but the invoice may still reflect her name. We'll make sure you get the email.
Thank you!
Bethany Georgoulias (she/her)
Environmental Engineer, Stormwater Program
DEMLR Laserfiche Administrator
Division of Energy, Mineral, and Land Resources
N.C. Department of Environmental Quality
919 707 3641 office
[e-mail]
DEQ is updating its email addresses to @deq.nc.gov in phases from May 1st to June 9th. Employee email addresses
may look different, but email performance will not be impacted.
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
From: Jacob Gill <[e-mail]>
Sent: Friday, May 26, 2023 10:02 AM
To: Georgoulias, Bethany<[e-mail]>; Randy A. Purol <[e-mail]>
Cc: Holloman, Tevye L <[e-mail]>
Subject: RE: [External] Certificate of Coverage Renewal
CAUTION: External email. Do not click links or open attachments unless verified. Report suspicious emails with the Report Message
button located on your Outlook menu bar on the Home tab.
Good morning Bethany —
Please list me as the contact for this development. Jennifer is no longer with Wallick, and I have taken over the
Carolinas.
Thank you!
Best,
Jake
Jake Gill I Development Manager
I°
^- 865.607.1668 1 160 West Main Street, Suite 200, New Albany, OH 43054
From: Georgoulias, Bethany
Sent: Friday, May 26, 2023 7:42 AM
To: Randy A. Purol

Cc: Jacob Gill; Holloman, Tevve L
Subject: RE: [External] Certificate of Coverage Renewal
You don't often get email from [e-mail]. Learn why this is important
Hi, Randy,
That COC was issued in June, so the annual fee invoice will go out June 15Y. Paying that is how you'll renew.
That invoice will be emailed out to the legally responsible person and site contact, currently
[e-mail] (listed for both). She is also the billing contact email. Please let us know as soon as
possible if someone else should be added as the billing contact to make sure that gets paid.
You'll also find the invoice and payment capability on June 1 on our website here:
https://www.deg.nc.gov/sw-ePayments
You just need to enter the COC number NCC222064
Be sure to coordinate payments with Jennifer, who'll get the invoice email, so there are no double payments (we don't
apply payments until the following day they are made, so they won't clear off the website for 24 hours if someone else
tries to pay as well).
I hope this information helps.
Best regards,
Bethany Georgoulias (she/her)
Environmental Engineer, Stormwater Program
DEMLR Laserfiche Administrator
Division of Energy, Mineral, and Land Resources
N.C. Department of Environmental Quality
919 707 3641 office
[e-mail]
DEQ is updating its email addresses to @deq.nc.gov in phases from May 1st to June 9th. Employee email addresses
may look different, but email performance will not be impacted.
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
From: Randy A. Purol <[e-mail]>
Sent: Thursday, May 25, 2023 4:12 PM
To: Georgoulias, Bethany<[e-mail]>
Cc: Jacob Gill <[e-mail]>; Randy A. Purol <[e-mail]>
Subject: [External] Certificate of Coverage Renewal
CAUTION: External email. Do not click links or open attachments unless verified. Report suspicious emails with the Report Message
button located on your Outlook menu bar on the Home tab.
Bethany,

The Certificate of Coverage for our Oak View at Siler City project is set to expire on 6/3/22. 1 attempted to complete the
online NPDES Stormwater Renewal COC Request form but am not able to type anything into the form. Can you assist or
direct me on how to get our renewal processed?
Our COC number is NCC222064.
Please call me at 313-215-0462 if you have any questions.
Thank you -
Randy Purol Project Manager
Construction
0 0",'-'­l ........
....
M....
,o......
.F..........
Fom...
........
m: 313.215.0462 1 160 West Main Street, Suite 200, New Albany, OH 43054
Confidentiality Notice
This Email transmission is intended for the use of the individual(s) to which it is addressed. It may contain information
that is privileged. This information is confidential and exempt from disclosure under applicable law.
If the reader of the message is not the intended recipient or the employee or agent responsible for delivering the
message to the recipient, you are hereby notified that any dissemination, distribution or copying of the communication
is strictly prohibited and may be a violation of Federal or State Law. If you have received this communication in error,
please notify the sender immediately and permanently delete the message.
Email correspondence to and from this address may be subject to the North Carolina Public Records Law and may be disclosed to third parties by an authorized
state official.
Confidentiality Notice
This Email transmission is intended for the use of the individual(s) to which it is addressed. It may contain information
that is privileged. This information is confidential and exempt from disclosure under applicable law.
If the reader of the message is not the intended recipient or the employee or agent responsible for delivering the
message to the recipient, you are hereby notified that any dissemination, distribution or copying of the communication
is strictly prohibited and may be a violation of Federal or State Law. If you have received this communication in error,
please notify the sender immediately and permanently delete the message.
Confidentiality Notice
This Email transmission is intended for the use of the individual(s) to which it is addressed. It may contain information
that is privileged. This information is confidential and exempt from disclosure under applicable law.
If the reader of the message is not the intended recipient or the employee or agent responsible for delivering the
message to the recipient, you are hereby notified that any dissemination, distribution or copying of the communication
is strictly prohibited and may be a violation of Federal or State Law. If you have received this communication in error,
please notify the sender immediately and permanently delete the message.
Confidentiality Notice
This Email transmission is intended for the use of the individual(s) to which it is addressed. It may contain information
that is privileged. This information is confidential and exempt from disclosure under applicable law.
If the reader of the message is not the intended recipient or the employee or agent responsible for delivering the
message to the recipient, you are hereby notified that any dissemination, distribution or copying of the communication

is strictly prohibited and may be a violation of Federal or State Law. If you have received this communication in error,
please notify the sender immediately and permanently delete the message.
Confidentiality Notice
This Email transmission is intended for the use of the individual(s) to which it is addressed. It may contain information
that is privileged. This information is confidential and exempt from disclosure under applicable law.
If the reader of the message is not the intended recipient or the employee or agent responsible for delivering the
message to the recipient, you are hereby notified that any dissemination, distribution or copying of the communication
is strictly prohibited and may be a violation of Federal or State Law. If you have received this communication in error,
please notify the sender immediately and permanently delete the message.