NCC203140_Contact Update Request (Leg Resp and Site Contact)_20220713

NCG01 Legally Responsible Individual Change Form
Use this form when:
The person who is legally responsible for the permit has changed, but there is NO CHANGE in the project name
or ownership.
**If the project name has changed, or if the ownership of the project has changed, do NOT use this form.**
Instead, you must submit a new NCGO1 electronic Notice of Intent (eNOl).
Directions:
Print this form, complete, scan and upload to the Construction Stormwater Permit MODIFICATION Form.
Then, mail the original form to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6`h Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM UNTIL YOUR MODIFICATION HAS BEEN REVIEWED AND ACCEPTED AS COMPLETE.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.221
Certificate of Coverage (COC) Number -J�: 1 -
Name of Project: �'bw)-J 6mx � �
Legally Responsible Organizational Entity: 56Xdr 'kU5-t4'C--
PREVIOUS Legally Responsible Individual: Tt GL 1�-k6AardS
NEW Legally Responsible Individual:
The following section is to be completed and signed by the NEW Legally Responsible Individual.
Per NC General Statute 143-215.6E (i), any person who knowingly makes any false statement, representation,
or certification in any application, record, report, plan, or other document filed or required to be maintained
under this Article or a rule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may
include a fine not to exceed ten thousand dollars ($10,000).
Page 1 of 2

NCG01 Legally Responsible Individual Change Form
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.22]
Under penalty of law, I certify that (check all boxes to indicate your agreement):
E]`�' I am the person responsible for the construction activities of this project, for satisfying the
requirements of this permit, and for any civil or criminal penalties incurred due to violations of this
permit.
I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and
Sediment Control Plan.
If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCGO10000 General Permit I will nonetheless ensure that all conditions of
Part 11 of the permit are met on the project at all times.
I understand that coverage under this permit will constitute the permit requirements for the
discharge(s) and is enforceable in the same manner as an individual permit.
This form has been reviewed and is accurate and complete to the best of my knowledge.
k.
*Signature:' cs _ Date: 4 '
Print Name of Signed: RL &C� 2
Title: bve tQ
Mailing Address: r Ors Cvli. 4 1nf j IUe 2. 4'
Street Address: (n� �E _r Pcm, WI-1 j {[ { V"- MC 12o
Email Address: Y 1.t* • ti 1\4AA ,loi.�I�oU.�S . C C7YY1
Phone Number: 91{i, ` M , �-TS Cbiy-0)_..... _.... _
* IMPORTANT NOTE. This form must be signed by a responsible corporate officer that owns or operates the
construction activity, such as a president, secretary, treasurer, or vice president, or a manager that is
authorized in accordance with Port IV, Section 8, Item (6) of the NCG010000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCG010000 permit.
Page 2 of 2

Georgoulias, Bethany
From:
Ruth Finch <[e-mail]>
Sent:
Wednesday, July 13, 2022 4:38 PM
To:
Georgoulias, Bethany
Cc:
Clark, Paul
Subject:
RE: [External] Re: Contact Changes for Stormwater Construction Permit NCC203140
Attachments:
DOC151.pdf
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
Bethany,
Thank you for the return call.
Attached please find the forms to update the account. I hope they are correct.
Ruth
From: Georgoulias, Bethany <[e-mail]>
Sent: Sunday, July 10, 2022 1:24 PM
To: Ruth Finch <[e-mail]>
Cc: Clark, Paul <[e-mail]>
Subject: RE: [External] Re: Contact Changes for Stormwater Construction Permit NCC203140
[EXTERNAL EMAIL] DO NOT CLICK links or attachments unless you recognize the sender and know the content is safe.
Hi, Ruth,
Thanks for the update. When the project close-out has been finalized, the permittee (someone within the Elderhaus, Inc.
organization) will be responsible for submitting a Notice of Termination. This is a very important step to conclude the
active permit status. A copy of the close-out documentation for the original Erosion and Sedimentation plan will be
required (attached for reference is the original approval from New Hanover County). I mention that the permittee must
submit the NOT request because if another person (like the architect) or organization submits on Elderhaus's behalf, the
request will not be approved.
The Notice of Termination (NOT) request is here:
https://edocs.deg.nc.gov/Forms/NCGOI-Termination
Let us know if you have any other questions.
Best,
Bethany Georgoulias (she/her)
Environmental Engineer

Stormwater Program, Division of Energy, Mineral, and Land Resources
N.C. Department of Environmental Quality
919 707 3641 office
[e-mail]
512 N. Salisbury Street, Raleigh, NC 27604 (location)
1612 Mail Service Center, Raleigh, NC 27699-1612 (mailing)
Website: http://deq.nc.gov/about/divisions/energy-mineral-land-resources/stormwater
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties
Based on the current guidance to minimize the spread of COVID-19, the Department of Environmental Quality has
adjusted operations to protect the health and safety of the staff and public. Many employees are working remotely or
are on staggered shifts. To accommodate these staffing changes, all DEQ office locations are limiting public access to
appointments only. Please check with the appropriate staff before visiting our offices, as we may be able to handle your
requests by phone or email. We appreciate your patience as we continue to serve the public during this challenging
time.
From: Ruth Finch <[e-mail]>
Sent: Sunday, July 10, 2022 10:49 AM
To: Georgoulias, Bethany <[e-mail]>
Subject: [External] Re: Contact Changes for Stormwater Construction Permit NCC203140
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
Bethany,
Following the first email, I contacted our construction lead at home office, he indicated that this should be
closed out and not an issue moving forward. Howard Resnick (spelling may be off) is the architect and he is
supposed to be taking care of this. We are waiting on a sign off for plants around the retention pond.
I will send a second email asking them to please resolve this issue ASAP.
Ruth
From: Georgoulias, Bethany <[e-mail]>
Sent: Friday, July 8, 2022 10:35 AM
To: Ruth Finch <[e-mail]>
Subject: RE: Contact Changes for Stormwater Construction Permit NCC203140
[EXTERNAL EMAIL] DO NOT CLICK links or attachments unless you recognize the sender and know the content is safe.

Good morning,
I have updated the billing information here, but I am unable to update the primary legally responsible individual and site
contact from Rick Richards without the attached form being completed. Please submit that as soon as possible so we
can get the other permit contact information up to date.
Thank you!
Bethany Georgoulias (she/her)
Environmental Engineer
Stormwater Program, Division of Energy, Mineral, and Land Resources
N.C. Department of Environmental Quality
919 707 3641 office
[e-mail]
512 N. Salisbury Street, Raleigh, NC 27604 (location)
1612 Mail Service Center, Raleigh, NC 27699-1612 (mailing)
Website: http://deq.nc.gov/about/divisions/energy-mineral-land-resources/stormwater
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties
Based on the current guidance to minimize the spread of COVID-19, the Department of Environmental Quality has
adjusted operations to protect the health and safety of the staff and public. Many employees are working remotely or
are on staggered shifts. To accommodate these staffing changes, all DEQ office locations are limiting public access to
appointments only. Please check with the appropriate staff before visiting our offices, as we may be able to handle your
requests by phone or email. We appreciate your patience as we continue to serve the public during this challenging
time.
From: Ruth Finch <[e-mail]>
Sent: Friday, July 1, 2022 8:20 AM
To: [e-mail]
Cc: Georgoulias, Bethany<[e-mail]>
Subject: [External] RE: Construction Stormwater Permit Annual Fee - NCC203140
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
Good morning!
Please send all invoices to [e-mail] for all outstanding invoices. I have forwarded this invoice
already.
Rick Richards retired in September of 2022. 1 am the new Executive Director for Elderhaus. Feel free to reach out to me
should you need information or have any questions.

Fxecut'welDieectar
� 1
Administrative Office
1380 North College Road
Wilmington, NC 28405
[phone]
[phone] (FAX)
[e-mail]
http://www.elderhaus.com/
Confidentiality Notice: This email message including any attachments is for the sole use of the intended
recipient(s) and may contain confidential and privileged information. Unauthorized use, review, disclosure, or
distribution is prohibited. If you are not the intended recipient, please contact the sender by reply email and
destroy all copies of the original message.
From: [e-mail] <[e-mail]>
Sent: Thursday, June 30, 2022 8:40 PM
To: Rick Richards <[e-mail]>
Cc: Rick Richards <[e-mail]>; [e-mail]
Subject: Construction Stormwater Permit Annual Fee - NCC203140
[EXTERNAL EMAIL] DO NOT CLICK links or attachments unless you recognize the sender and know the content is safe.
Attached is the 2022 annual fee invoice for your Construction Stormwater NPDES permit, COC no. NCC203140. When
using the ePayment website, be sure to enter ONLY the COC number (not the invoice number with "-2022" after it).
Please contact Danny Smith at [e-mail] or Kieu Tran at [e-mail] with any questions.
If this project has been closed out, you must submit a Notice of Termination (NOT) request here:
https://edocs.deg. nc.gov/Forms/NCGOI-Termi nation
Sincerely,
The DEMLR Stormwater Program
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