NCG140435_Permit Contact Update Request_20220405

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 4/5/2022 9:07:49 AM (Permit Contact Update Request)
Approve by Tran, Kieu M 4/5/2022 10:50:57 AM (Contact Update Review)
IN For Electronic Signature Authorization, please go to Step 2: Submit eReporting Registration Form and
follow the directions listed below. https://deq.nc.gov/about/divisions/energy-mineral-and-land-
resou rces/stormwater/stormwater-prog ram/npdes-industrial-prog ram/stormwater-electron ic-discharge-
mon itoring-reports-ed m r/six-step-process#step-2--submit-ereporting-registration-form
• Georgoulias, Bethany A reassigned the task to Tran, Kieu M 4/5/2022 10:29 AM
The task was assigned to Georgoulias, Bethany A. The due date is: May 17, 2022 5:00 PM
4/5/2022 9:08 AM

Request Submitted
NPDES Permit Enter your NPDES stormwater permit number or Certificate of Coverage (COC) number.
Number* NCG140435
Begins with NCS, NCG, or NCGNE (no exposure)
Facility Name* American Concrete 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
Kevin Stroupe
E-mail Address* [e-mail]
Phone No.* 828-443-0034
Mailing Address* 2698 Mount Home Church Rd
Morganton, NC 28655
Physical Address If different than mailing address
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
Michelle Stroupe
E-mail Address* [e-mail]
Phone No.* 828-437-1348
Mailing Address* 2698 Mount Home Church Rd
Morganton, NC 28655

Physical Address If different than mailing address
Add another permit contact if needed by clicking the'Add' button below
Facility Contact Update
Provide new facility contact information
This person should REPLACE the current facility contact.
This person should just be added as another facility contact.
New Contact Name* First and Last Name
Kevin Stroupe
E-mail Address* [e-mail]
Phone No.* 828-443-0034
Mailing Address* 2698 Mount Home Church Rd
Morganton, NC 28655
Physical Address If different than mailing address
Add another facility contact if needed by clicking the 'Add' button below
Other Contact Updates
Only use this section if none of the categories above apply.
Provide details about *Person(s) with Electronic Signature Authority*
another contact
update: * Michelle Stroupe
americanconcrete21 @gmail.com
828-437-1348
2698 Mount Home Church Rd
Morganton, NC 28655
Submitter's Name* Please enter your FIRST and LAST name
Kevin Stroupe
Phone Number* Please enter your phone number
828-443-0034
Any format is fine.
Email Address* Please enter a valid e-mail address
americanconcrete21 @gmail.com
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
Cfi} , llOW1117K
Date 4/5/2022
Questions? Contact [e-mail].

Review
Verify Permit No.* Revise permit number below if incorrect.
N CG 140435