NCG060354_Owner Affiliation Change Request_4/6/2020

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 4/6/2020 1:34:29 PM (Owner Affiliation Change Submission)
Approve by McCoy, Suzanne 4/14/2020 7:42:44 AM (Notification to Admin)
• The task was assigned to McCoy, Suzanne 4/6/2020 1:34 PM

1 S
�i.
mnvV��
NORTH CARCLINA
Emlmnm MI Quat<ty
Default Page
NPDES Permit
Enter your MPDES storrrwater pernit nunber or Certificate of Coverage (COC) nunber.
Number*
NCG060354
NCS)00000(orNQG)00000(
Submittor's Name*
Please enter your FIRST and LAST narre
Samuel Toke
Phone Number*
Reaseenter your phone nunber
252-822-2867
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 Reaseupload the signed "FbrnitCwnerAffiliation Designation Fornl'
Upload* NCG060354.pdf 547.48KB
pdf only

Initial Review
Project ID * Reviewer may revise permt nunber below if incorrect.
NCG060354