NCG030612_Owner Affiliation Change Request_12/13/2019

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 12/13/2019 9:13:04 AM (Owner Affiliation Change Submission)
Approve by McCoy, Suzanne 12/13/2019 1:41:41 PM (Notification to Admin)
• The task was assigned to McCoy, Suzanne 12/13/2019 9:13 AM

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Default Page
NPDES Permit
Enter your NPIDES storrrwater pernit nunber or Certificate of Coverage (COC) nunber.
Number*
NCG030612
NCS)00000(or NCC)00000(
Submittor's Name*
Reaseenter your FIRST and LAST narre
Deborah McCollum
Phone Number*
Reaseenter your phone nurrber
336-662-0113
Any format is fine.
Email Address *
Rease enter a valid a -mail address
[e-mail]
A confirmation of submssion will be e-mailed to this address.
Need a copy of the Permit Owner Affiliation Designation Form? You must upload a signed copy of that form below.
Questions? Call Bethany Georgoulias at [phone] or e-mail her at.bethany.georgouliasencdenr.gov.
Completed Form Rease upload the signed "Permit Owner Affiliation Designation Forn'
Upload* Permit Owner Affiliation Designation Form.pdf 1.01 MB
pdr only

Initial Review
Project ID * Peviewer rmy revise perrrit nunber below if incorrect.
NCG030612