NCG060373_Permit Contact Update Request_20220314

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 3/14/2022 2:15:44 PM (Permit Contact Update Request)
Approve by Tran, Kieu M 3/15/2022 10:28:21 AM (Contact Update Review)
IN Revised BIMS 3/15/2022
• Georgoulias, Bethany A reassigned the task to Tran, Kieu M 3/15/2022 8:03 AM
• Georgoulias, Bethany A reassigned the task to Georgoulias, Bethany A 3/14/2022 4:33 PM
• Georgoulias, Bethany A reassigned the task to McCoy, Suzanne 3/14/2022 4:20 PM
10 For training
• The task was assigned to Georgoulias, Bethany A. The due date is: April 25, 2022 5:00 PM
3/14/2022 2:15 PM

Request Submitted
NPDES Permit Enter your NPDES stormwater permit number or Certificate of Coverage (COC) number.
Number* NCG060373
Begins with NCS, NCG, or NCGNE (no exposure)
Facility Name* Brakebush Brothers, Inc.
(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
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
David Bullins
E-mail Address* [e-mail]
Phone No.* 800-933-2121 3345
Mailing Address* 251 Eaton Rd, Mocksville, NC 27028
Physical Address If different than mailing address
Add another permit contact if needed by clicking the 'Add' button below
Submitter's Name * Please enter your FIRST and LAST name
Peter Lemke
Phone Number* Please enter your phone number
9203584132
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 3/14/2022
Questions? Contact [e-mail].

Review
Verify Permit No.* Revise permit number below if incorrect.
NCG060373