NCG050243_Permit Contact Update Request_20230808

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by Anonymous User 8/8/2023 7:52:46 AM(Permit Contact Update Request)
Approve by Joyce Sanford 9/20/2023 12:20:04 PM(Contact Update Review)
• The task was assigned to DEMLR SW Admin General.The due date is: September 19,2023 5:00 PM
8/8/2023 7:52:52 AM
• The task was assigned to Joyce Sanford by round robin distribution 8/8/2023 7:52:52 AM

DEQIwo NPDES Stormwater -Request
Request Submitted
NPDES Permit Enter your NPDES stormwater permit number or Certificate of Coverage(COC)number.
Number* NCG050243
Begins with NCS,NCG,or NCGNE(no exposure)
Facility Name* Acucote Incorporated-Graham
(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
Owner Affiliation (Legally Responsible Individual) Change
Upload a copy of the completed and signed Permit Owner Affiliation Designation Form below.We can begin making
updates with this submittal, but please note that you must mail in the original signed copy to our office,in
accordance with requirements in 40 CFR 122.22.
Staff may contact you to confirm the requested change if this Owner is also associated with other permits in our system.
Changes to Owner Affiliation affect all permits tied to that Owner.
Owner Affiliation Please upload the signed"Permit Owner Affiliation Designation Form"
Change Form Upload PERMIT OWNER AFFILIATION.pdf 438.48KB
pdf only
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
Max Broome
E-mail Address* [e-mail]
Phone No.* 336-867-0589
Mailing Address* 910 ESAT ELM STREET
GRAHAM , NC 27253

Physical Address If different than mailing address
Add another permit contact if needed by clicking the'Add'button below
Person(s) with Delegation of Signature Authority (DOSA)
Delegation of Please upload the signed"Stormwater Permit Delegation of Signature Authority Form"
Signature Authority STORMWATER DELIGATION FORM.pdf 607.16KB
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
Max Broome
E-mail Address* [e-mail]
Phone No.* 336-867-0589
Mailing Address* 910 EAST ELM STREET
GRAHAM, NC 27253
Physical Address If different than mailing address
Add another facility contact if needed by clicking the'Add'button below
Other Contact Updates
Only use this section if none of the categories above apply.
Provide details about Max Broome,Safety Director
another contact
update:*
Submitter's Name* Please enter your FIRST and LAST name
Max Broome
Phone Number* Please enter your phone number
336-867-0589
Any format is fine.
Email Address* Please enter a valid e-mail address
[e-mail]
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 8/8/2023
Questions? Contact [e-mail].

Review
Verify Permit No.* Revise permit number below if incorrect.
NCG050243