NCG140003_Name-Owner Change Request_20220809

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 8/9/2022 11:57:40 AM (Name Owner Change Request)
Approve by Tran, Kieu M 8/12/2022 10:08:34 AM (Name Owner Change Review)
• The task was assigned to Tran, Kieu M. The due date is: September 20, 2022 5:00 PM
8/9/2022 11:57 AM

Application
Facility Name* Childers Concrete Company
NPDES Permit Enter your NPDES stormwater permit number or Certificate of Coverage (COC) number.
Number* NCG140003
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 Storm Water Permit Name Change Form.PDF 696.74KB
pdf only
Supporting Please upload any supporting documents (if separate from above)
Documents Upload pdf only
Submitter's Name Please enter your FIRST and LAST name
Mitchell Childers Jr
Phone Number* Please enter your phone number
336-841-3111
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 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
fllNell CUCII- s ,Tr
Date * 8/9/2022
Questions? Contact [e-mail].

Review
Verify Permit No.* Revise permit number below if incorrect.
N CG 140003
Review Date* 8/12/2022