NCG140396_Permit Contact Update Request_20220615

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 6/15/2022 11:47:27 AM (Permit Contact Update Request)
Approve by Tran, Kieu M 6/17/2022 8:36:13 AM (Contact Update Review)
• The task was assigned to Tran, Kieu M. The due date is: July 27, 2022 5:00 PM 6/15/2022 11:47 AM

Request Submitted
NPDES Permit Enter your NPDES stormwater permit number or Certificate of Coverage (COC) number.
Number* NCG140396
Begins with NCS, NCG, or NCGNE (no exposure)
Facility Name* DPD Team Concrete-Grantsboro
(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
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
Note: This person will REPLACE the current billing contact. We can only designate one billing contact in our
permitting database.
New Contact Name* First and Last Name
Lori Manke
E-mail Address*
[e-mail]
Phone No.*
2527560119
Mailing Address*
PO Box 1639
Winterville, NC 28590
Physical Address
If different than mailing address
5039 NC 11 South
Winterville, NC 28590
Facility Contact Update
Provide new facility contact information
..............................
ii 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
David Hardee
E-mail Address* [e-mail]
Phone No.* 2525311328
Mailing Address*
PO Box 1639
Winterville, NC 28590
Physical Address
If different than mailing address
5039 NC 11 South
Winterville, NC 28590
Add another facility contact
if needed by clicking the 'Add' button below
Submitter's Name*
Please enter your FIRST and LAST name
Lori Manke
Phone Number* Please enter your phone number
2527560119
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 6/15/2022
Questions? Contact [e-mail].

Review
Verify Permit No.* Revise permit number below if incorrect.
N CG 140396