NCG060174_Owner Affiliation Change Requests_20211103

Georgoulias, Bethany
From: Georgoulias, Bethany
Sent: Wednesday, November 3, 2021 8:35 AM
To: Pedley, Tina
Subject: RE: [Ext]- RE: [External] NCG060174 and NCG060379
Tina,
N CG 060174
NCG060379
have both had the Owner -Owner Affiliation updated to Daniel Shaw.
Other permits where this change will take effect:
Stormwater Permits
NCG060182
N CG 060184
Other Water Quality Permits
NC0072575
NCG590023
WQ0005681
WQ0014565
WQ0028653
WQCSD0386 (deemed permitted collection system)
You can run a Permit Summary Report for any of the NCG06 COCs and confirm the change tomorrow.
Best,
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
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties
1

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: Pedley, Tina [mailto:[e-mail]]
Sent: Wednesday, November 3, 2021 8:19 AM
To: Georgoulias, Bethany <[e-mail]>
Subject: Re: [Ext]- RE: [External] NCG060174 and NCG060379
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
Yes. I was trying to get them all changed over and working on paperwork for them as well.:)
Sent from my iPhone
On Nov 3, 2021, at 8:14 AM, Georgoulias, Bethany<[e-mail]> wrote:
*Use caution before opening attachments or links!*
Good morning,
Before I make this change, I want to make sure it's okay that it will also change the person tied to some
other program permits as well, specifically several non -discharge WW Irrigation and residual solids
permits (that begin with WQ), as well as the wastewater permit NCG590023 (Sanford Water Treatment
Plant) for backwash water from that system.
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
<image001.jpg>
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: Pedley, Tina [mailto:[e-mail]]
Sent: Tuesday, November 2, 2021 9:15 AM
To: Georgoulias, Bethany<[e-mail]>
Subject: RE: [External] NCG060174 and NCG060379
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an
attachment to Report Spam.
Good morning, Attached are both. I will also send a hard copy in the mail to the address listed. Thanks
for the help
From: Georgoulias, Bethany [mailto:[e-mail]]
Sent: Wednesday, October 27, 2021 2:20 PM
To: Pedley, Tina <[e-mail]>
Subject: [Ext]- RE: [External] NCG060174 and NCG060379
*Use caution before opening attachments or links!*
Tina,
Because he is listed as the Owner -Owner affiliation for both of these, you need to submit a change
request via this form:
https://edocs.deg.nc.gov/Forms/SW-Owner-AffiIiation
Attached is the form that the new Owner Affiliation must sign and upload with the online form.
Suzanne McCoy's last day with us was Friday, so the position that processes these is vacant right
now. Please go ahead and submit the request, but it may be some time before it's processed. Feel free
to check in with me on the status.
Thanks,
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
<1mage003.jpg>
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: Pedley, Tina[mailto:[e-mail]]
Sent: Wednesday, October 27, 2021 11:02 AM
To: Pedley, Tina <[e-mail]>; McCoy, Suzanne <[e-mail]>
Cc: Georgoulias, Bethany<[e-mail]>
Subject: [External] NCG060174 and NCG060379
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an
attachment to Report Spam.
Good morning
We have a new complex manager. I need to get Daniel Shaw added and Jamal Mohammed
removed. Can you let me know what I need to fill out for these 2 permits? thanks
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Division of Energy, Mineral, and Land Resources
Land Quality Section It Stormwater Program
N, National Pollutant Discharge Elimination System (NPDES)
Energy. Mineral & PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resources
ENVIRONMENTAL OVALITY (Individual Legally Responsible for Permit)
Use this form if there has been:
FOR AGENCY USE ONLY
Date Received
Year
Month
Da
NO CHANGE in facility ownership or facility name, but the individual
who is legally responsible for the permit has changed.
If the name of the facility has changed, or if the ownership of the facility has changed,
do NOT use this form. Instead, you must rill out a Name -Ownership Change Form
and submit the completed form with all required documentation.
What does "legally responsible individual" mean?
The person is either:
• the responsible corporate officer (for a corporation);
• the principle executive officer or ranking elected official (for a municipality, state, federal or other public
agency);
• the general partner or proprietor (for a partnership or sole proprietorship);
• or, the duly authorized representative of one of the above.
1) Enter the permit number for which this change in Legally Responsible Individual ("Owner Affiliation")
applies:
Individual Permit (or) Certificate of Coverage or No Exposure
N I C I S N I C I G-0 1 (p p
2) Facility Information:
Facility name:
Company/Owner Organization: `Pi W : M
Facility address: LA%I� 'Z-; mr,nerenoA Rd
Address
-5 nf>,rc( f&- a?330
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
https://deg.nc.gov/about/divisions/energy-mineral-land-resources/energy-mineral-land-permits/npdes-industrial-
rp ogram and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: ISIMPA byyx me-(
First MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: �)CN,eA
First MI Last
Page 1 of 2
S WU-O WNE RAF FIL4Nov2o19

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
Cep ma�a,�
itle
L M M tr r n C-.O
Mailing Address
sc'AftrCl Jjc 0173 o
City State Zip
06 ) bqS 3 45 do.0+R1.51n0w e 6(;Ms'cam
Telephone E-mail Address
Fax Number
5) Reason for this change:
Employee or management change
A result of: Inappropriate or incorrect designation before
❑ Other
If other please explain:
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
�E L_ attest that this application for this change in Owner Affiliation
(person legally responsible for the permit) has been reviewed and is accurate and complete to the best of my
knowledge. I understand that if all required parts of this form are not completed, this change may not be
processed.
2
-L
Signature Date
PLEASE SEND THE COMPLETED FORM TO:
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
For more information or staff contacts, please call [phone] or visit the website
at: http://deg.nc.gov/about/divisions/energy-mineral-land-resources/stormwater
Page 2 of 2
S WU-OWN ERAFFIL-4Nov20I 9

Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
Energy. Mineral & PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resources £NVIROFiM ENTAL QUALITY (individual Legally Responsible for Permit)
Use this form if there has been:
FOR AGENCY USE ONLY
Dam Received
Year
Month
Day
NO CHANGE in facility ownership or facility name, but the individual
who is legally responsible for the permit has changed.
If the name of the facility has changed, or if the ownership of the facility has changed,
do NOT use this form. Instead, you must fill out a Name -Ownership Change Form
and submit the completed form with all required documentation.
What does "legally responsible individual" mean?
The person is either:
• the responsible corporate officer (for a corporation);
• the principle executive officer or ranking elected official (for a municipality, state, federal or other public
agency);
• the general partner or proprietor (for a partnership or sole proprietorship);
• or, the duly authorized representative of one of the above.
1) Enter the permit number for which this change in Legally Responsible Individual ("Owner Affiliation")
applies:
Individual Permit
N C 5
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
(or) Certificate of Coverage or No Exposure
N I C I G I p W D 3 -7
A (v.
_ _ 1'ticr�mS
&A
Address
.Zi'J S S
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
https:Hdeg.nc.gov/about/divisions/energy-mineral-land-resources; energy-mineral-land-permits/npdes-industrial-
rp ogram and run the Permit Contact Summary Report. _
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: J ywo-1 M,66'Am'ot
First MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
(N. QA � V
First MI Last
Page 1 of 2
S WU-O WNERAF F1L4Nov2014

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
FIT
y%Ll I;
Mailing Address
stykrd A3c, 2233�
City State Zip
l�ltg ) %q5 -mss do._n'd ems. ccs,k
Telephone E-mail Address
Fax Number
5) Reason for this change:
A result of: Employee or management change
❑ Inappropriate or incorrect designation before
❑ Other
If other please explain:
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
I, S A& tt i _, attest that this application for this change in Owner Affiliation
(person legally responsible for the permit) has been reviewed and is accurate and complete to the best of my
knowledge. 1 understand that if all required parts of this form are not completed, this change may not be
processed.
Signature Date
PLEASE SEND THE COMPLETED FORM TO:
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
For more information or staff contacts, please call [phone] or visit the website
at: h ://de .nc. ov/about/divisions/ener -mineral-land-resources/stormwater
Page 2 of 2
S WU-O WNERAFFIL-4Nov2019