NCG030195_Permit Contact Update Request_20220503

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 5/3/2022 11:18:06 AM (Permit Contact Update Request)
Approve by Tran, Kieu M 5/4/2022 1:43:46 PM (Contact Update Review)
• The task was assigned to Tran, Kieu M. The due date is: June 14, 2022 5:00 PM 5/3/2022 11:18 AM

Request Submitted
NPDES Permit Enter your NPDES stormwater permit number or Certificate of Coverage (COC) number.
Number* NCG030195
Begins with NCS, NCG, or NCGNE (no exposure)
Facility Name* Imperial Brown, 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
Owner Affiliation (Legally Responsible Individual) Change
Upload a copy of the completed and signed Permit Owner Affiliation Designation 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.
Staff may contact you to confirm the requested change if this Owner is also associated with other permits in our system.
Changes to Owner Affiliation affect all permits tied to that Owner.
Owner Affiliation Please upload the signed "Permit Owner Affiliation Designation Form"
Change Form Upload ImperialBrown PermitOwnerAffiIiationForm032622F... 1.17MB
pdf only
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
Ken Rhoads
E-mail Address* [e-mail]
Phone No.* 503-706-6060
Mailing Address* Imperial Brown, Inc.
209 Long Meadow Drive
Salisbury, NC 28147

Physical Address If different than mailing address
Add another permit contact if needed by clicking the 'Add' button below
Stormwater Program's Billing Specialist will be notified about the billing update request by email upon approval.
Billing Contact Update
Provide new billing contact information
This person should REPLACE the current billing contact.
This person should just be added as another billing contact.
New Contact Name* First and Last Name
Rex Plombon
E-mail Address* [e-mail]
Phone No.* 503-517-3651
Mailing Address* Imperial Brown, Inc.
198 SE 223rd Ave.
Gresham. OR 97030
Physical Address If different than mailing address
Person(s) with Delegation of Signature Authority (DOSA)
Delegation of Please upload the signed "Stormwater Permit Delegation of Signature Authority Form"
Signature Authority ImperialBrownStromwater Permit Delegation of
1.86MB
Signature Authority form041422Final. pdf
pdf only
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
Chris Straughn
E-mail Address* [e-mail]
Phone No.* 704-202-8806
Mailing Address* Imperial Brown, Inc.
209 Long Meadow Drive
Salisbury, NC 28147
Physical Address If different than mailing address
Add another facility contact if needed by clicking the 'Add' button below
Submitter's Name* Please enter your FIRST and LAST name
James T. Horne, PE

Phone Number* Please enter your phone number
704-798-7730
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
WAlf, P_t z`d form
Date 5/3/2022
Questions? Contact [e-mail].

Review
Verify Permit No.* Revise permit number below if incorrect.
NCG030195