Loading...
HomeMy WebLinkAboutNCG080582_Permit Contact Update Request_20220818Action History (UTC-05:00) Eastern Time (US & Canada) Submit by Anonymous User 8/18/2022 5:23:30 PM (Permit Contact Update Request) Approve by Tran, Kieu M 8/19/2022 8:27:49 AM (Contact Update Review) • The task was assigned to Tran, Kieu M. The due date is: September 29, 2022 5:00 PM 8/18/2022 5:23 PM Request Submitted NPDES Permit Enter your NPDES stormwater permit number or Certificate of Coverage (COC) number. Number* NCG080582 Begins with NCS, NCG, or NCGNE (no exposure) Facility Name* Maverick Specialized (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 Owner Affiliation Change Form- Maverick.pdf 801.93KB 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 Perry Harrison E-mail Address* pharrison@maverickusa.com Phone No.* (501) 955-1316 Mailing Address* Maverick Transportation, LLC. PO Box 16173 Little Rock, AR. 72231 Physical Address If different than mailing address Maverick Transportation, LLC. 13301 Valentine Rd. North Little Rock, AR. 72117 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 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 Dottie Rippee E-mail Address* accountspayable@maverickusa.com Phone No.* (501) 955-1292 Mailing Address* Maverick Real Estate, LLC. PO Box 16173 Little Rock, AR. 72231 Physical Address If different than mailing address Maverick Real Estate, LLC. 13301 Valentine Rd. North Little Rock, AR. 72117 Submitter's Name* Please enter your FIRST and LAST name Perry Harrison Phone Number* Please enter your phone number (501) 955-1316 Any format is fine. Email Address* Please enter a valid e-mail address pharrison@maverickusa.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] ff Date 8/18/2022 Questions? Contact bethany.georgoulias@ncdenr.gov. Review Verify Permit No.* Revise permit number below if incorrect. NCG080582