NCC205388_Contact Update Request (LEG RESP CHANGE)_20211012

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, 6th 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
Certificate of Coverage (COC) Number: NCC205388
Name of Project: Wendell -Knightdale Connection
Legally Responsible Organizational Entity: Public Service Company of North Carolina, Inc.
PREVIOUS Legally Responsible Individual: Shaun Randall
NEW Legally Responsible Individual: Andrew Moore
The following section is to be completed and signed by the NEW Legally Responsible Individual.
Per NC General Statute 143-215.6E (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
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.
1 will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
21"� 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 11 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.
Yr This form has been reviewed and is accurate and complete to the best of my knowledge.
*Signature: �� Date: 16/12 /2-02.1
Print Name of Signed: Andrew Mbore
Title: Director - Engineering & Construction
Mailing Address: P.O. Box 1398, Gastonia, NC 28053
Street Address: 800 Gaston Road, Gastonia, NC 28056
Email Address: [e-mail]
Phone Number: 704-810-3259
* 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 NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCGO10000 permit.
Page 2 of 2

Georgoulias, Bethany
From: Liane Rene Morgan <[e-mail]>
Sent: Tuesday, October 12, 2021 12:08 PM
To: Georgoulias, Bethany
Subject: [External] RE: Construction SW Modification Request Received (NCC205388)
Attachments: NameChange 115314.pdf
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
Hi Bethany
Not sure if Andrew forwarded this form to you but here it is just in case he hasn't.
Let me know if you need anything else.
Thanks!!
Liane R. Morgan, P.E
Senior Project Manager
S&ME
• 2016 Ayrsley Town Blvd., Suite 2-A
Charlotte, NC 28273 map
� 0: 704.523.4726 ext, 11652
M: 704.989.0672
www.smeinc.com
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From: Georgoulias, Bethany <[e-mail]>
Sent: Monday, October 11, 2021 7:54 AM
To: [e-mail]
Cc: Liane Rene Morgan <[e-mail]>; [e-mail];
[e-mail]
Subject: RE: Construction SW Modification Request Received (NCC205388)
Importance: High
This message originated outside of S&ME. Please report this as phishing if it implies it is from an S&ME
employee.
Mr. Moore,
1

This modification request indicated there was a change in legally responsible person, but the form for that was not
uploaded. If you will fill the attached form out and email it back to me, I can process the Mod request and make the
change.
Thank you,
Bethany Georgoulias (she/her)
Environmental Engineer
Stormwater Program, Division of Energy, Mineral, and Land Resources
N.C. Department of Environmental Quality
919 707 3641 office
[e-mail]
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
es!5:fREQ1�
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties
Based on the current guidance to minimize the spread of COVID-19, the Department of Environmental Quality has
adjusted operations to protect the health and safety of the staff and public. Many employees are working remotely or
are on staggered shifts. To accommodate these staffing changes, all DEQ office locations are limiting public access to
appointments only. Please check with the appropriate staff before visiting our offices, as we may be able to handle your
requests by phone or email. We appreciate your patience as we continue to serve the public during this challenging
time.
From: [e-mail] [mailto:[e-mail]]
Sent: Friday, October 8, 2021 12:50 PM
To: [e-mail]
Cc: [e-mail]; [e-mail]; [e-mail]
Subject: Construction SW Modification Request Received
Thank you for submitting a Modification request for Wendell-Knightdale Connection in Wake County,
Certificate of Coverage (COC) no. NCC205388.
Modification Reason: Other Revision(s) to E&SC Plan
Additional Details (fprovided): Addition of workspace and thus increase in limits of disturbance. Also,
modification of legally responsible individual.
If your submittal is accepted, you will receive e-mail confirmation. You will also be notified if additional
information is needed or if the modification request or documents cannot be accepted.
If you have any questions, please contact bethany_geor og uliasgncdenr.gov.
Be sure to add [e-mail] to your contacts to avoidfuture e-mails about this application from
going into Spam falters.

The NC DEMLR Stormwater Program
512 N. Salisbury Street, Archdale Building 6th Floor, 1612 Mail Service Center, Raleigh, NC 27699-1612
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