NCG030689_Name-Owner Change Request_20220330

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 3/30/2022 6:58:07 AM (Name Owner Change Request)
Approve by Tran, Kieu M 3/30/2022 8:49:36 AM (Name Owner Change Review)
• Georgoulias, Bethany A reassigned the task to Tran, Kieu M 3/30/2022 8:09 AM
• The task was assigned to DEMLR SW Admin. The due date is: May 11, 2022 5:00 PM
3/30/2022 6:58 AM

Application
Facility Name* AW North Carolina
NPDES Permit Enter your NPDES stormwater permit number or Certificate of Coverage (COC) number.
Number* NCG030689
Begins with NCS, NCG, or NCGNE (no exposure)
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 current owner and facility information for the permit by running a Stormwater Permit Summary Report.
Name/Owner Change Application Upload
Upload a copy of the completed and signed Permit Name/Owner Change Form below. We can begin making updates with
this submittal, but please note that you must mail in the original signed copy to our office, in accordance with
requirements in 40 CFR 122.22.
Name/Owner Change Please upload the signed "Permit Name/Owner Change Form"
Form Upload
Name Change Form.pdf 633.16KB
pdf only
Supporting
Please upload any supporting documents (if separate from above)
Documents Upload
Name Change.pdf 137.49KB
pdf only
Submitter's Name
Please enter your FIRST and LAST name
Benjamin Payne
Phone Number*
Please enter your phone number
919-519-3379
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.
* v 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 the completed Name/Owner Change Form, which also must be mailed in with original signature);
AND
I intend to electronically sign and submit this Name/Ownership Change Request form.

Signature
Owl"'Wew, 9�
Date * 3/30/2022
Questions? Contact [e-mail].

Review
Verify Permit No.* Revise permit number below if incorrect.
NCG030689
Review Date* 3/30/2022