NC0082384_Owner (Name Change) Form_20220831

Submitted Form
Please note: fields marked with a red asterisk " below are required. You will not be able to submit the form until all mandatory questions are
answered.
Project Contact Information
Please provide information on the person to be contacted by NPDESB Staff regarding electronic submittal, confirmation of receipt, and other issues.
Contact Name* Name Change Test - Accept
Email Address* Phone Number*
[e-mail] 4444444444 J
Project Information
..................................................................................
Submittal Type*
New Application
Renewal Application
Delegation of Signature Authority
Name/Ownership/Legally Responsible
Change
Permit Number*
NCO082384
Project id must have 9 characters.
Applicant/Permittee *
Name Change Test - Accept
Applicant/Permittee Address*
1234 Test Lane
Facility Name*
Name Change Test - Accept
County*
Stokes
Modification Application (Major or Minor)
Additional Information Response
Annual Report
Other
Please attach all information required or requested for this submittal to be reviewed here.*
(Application Form, Engineering Plans, Specifications, Calculations, Etc.)
Parameter Codes - Regularly Used.pdf
Only pdfs are allow to be attached. Upload only 1 PDF document. Multiple documents must be combined into one PDF file.

Please provide comments/notes on your current submittal below.
Third Test - 8/31/2022 - Name Change Test - Accept Submittal
For permit applications, a paper copy with original signature is required to be submitted. Only one paper copy is required. Applications
are accepted for pre -review only until the electronic and paper copies as well as any required fees have been received. The paper copy
(and fee if required) shall be submitted to:
Mailing address:
By Courier/Special Delivery
By U.S. Postal Service
Division of Water Resources Division of Water Resources
NPDES Permitting Branch NPDES Permitting Branch
1617 Mail Service Center Att: Wren Thedford, 9th Floor, Archdale Building
Raleigh, NC 27699-1617 512 N. Salisbury Street
Raleigh, NC 27604-1170
For questions or problems contact Wren Thedford at [e-mail].
* By checking this box and signing below I certify that
• I understand the application will not be accepted for pre -review until the paper copy (if required) and fee (if required) have been
received by the NPDES Permitting Branch.
• I also confirm that the uploaded document is a single PDF with all parts of the application in correct order (as specified by the
application).
• 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; AND
• I intend to electronically sign and submit the online form."
Submittal Date 8/31/2022
Signature

Initial Review
Does this project meet all Yes
the requirements for No
acceptance?
Updated ID# NCO082384
Reviewer List* Bradley Bennett
Comments for the
Supervisor:
Comments for Email to Comments for Submitter- Third 8/31/22 - Name Change Accept
Submitter
Comments for Reviewer Comments for Reviewer- Third 8/31/22 - Name Change Accept
Email:
Reviewed By Bennett, Tilman B
Intial Review Completion 8/31/2022
Date