NCC216034_Contact Update Request (Legally Resp Change)_20221010

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 NCG01 electronic Notice of Intent (eNOI).
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, 6th 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: Ai �193�
Name of Project: 7 1lr�l1 �r � Ge4,4 �.
risible Oreanizat?onal Ent
PREVIOUS Leeally Responsible Individual:
NEW Legally Responsible Individual: ( an rl S
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

. 111111 11• • s
Under penalty of law, I certify that (check all boxes to indicate your agreement):
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 NCG010000 General Permit, 1 will nonetheless ensure that all conditions of
Part it 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.
*Signature: Date: ��—
c
Print Name of Si e .
Title: a-K,
Mailing Address: ' 1A p��t\�r� �� q
-
Street Address: I .C)� „ v-41 q 061
Email Address:
Phone Number: / !) `) \ I n I 'I --
* 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 Part IV, Section 8, Item (6) of the NCG010000 permit.
For more information on signatory requirements, see Part IV, Section 8, Item (6) of the NCG010000 permit.
Page 2 of 2

Georgoulias, Bethany
From: Christine Early <[e-mail]>
Sent: Friday, October 7, 2022 5:24 PM
To: Georgoulias, Bethany
Cc: Katy Breazeale
Subject: FW: [External] FW: Construction SW Permit Contact Information Update for
NCC216034
Attachments: NCG01 Legal Responsible Individual Change Form for HG 10-7-22.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,
Good afternoon. Please find the attached form her for the individual change for the Harper's Glen NCG01 permit. I'm
also putting the original in the mail.
Thanks and have a great weekend!
Christine Early
Director of Acquisitions
Exeter Development Company
[e-mail]
757-619-0423
CONFIDENTIALITY NOTICE: The information contained in the body or any
attachments in this email is solely for the intended recipient(s). All
information herein from Exeter Development Company LLC is confidential, may
be proprietary and shall not be disseminated, copied, distributed or
disclosed without the written authorization of the sender. Failure to comply
with the above provision may be unlawful. If you are not the intended
recipient or have been forwarded this message void of specific instructions
from the author to do so, please immediately notify the sender and/or author
that you have received the message and then delete the message and any
attachment without viewing any of the content beyond this notice.
From: Katy Breazeale <[e-mail]>
Sent: Friday, October 7, 2022 4:43 PM
To: Christine Early <[e-mail]>
Subject: FW: [External] FW: Construction SW Permit Contact Information Update for NCC216034
THIS CAN WAIT UNTIL MONDAY, but I was worried I would forget if I didn't go ahead and send. If you can print and sign
and scan back to the email address below, they can go ahead and make the change. Then if you don't mind, just drop
the original in the mail to the address on the form. Let me know if you need anything else. Thank you.

Katy Breazeale, CPA
CFO
Exeter Development Company
1905 Woodstock Rd
Suite 9250
Roswell, GA 30075
[e-mail]
[phone]
From: Georgoulias, Bethany<[e-mail]>
Sent: Wednesday, October 5, 2022 10:55 AM
To: Katy Breazeale <[e-mail]>
Subject: RE: [External] FW: Construction SW Permit Contact Information Update for NCC216034
Katy,
That takes another step. A change in legally responsible person requires the attached form to be completed and signed
by the new person. You can send a scanned copy to me via email, but the original wet -signed copy also needs to be
mailed to our office (EPA requirement). I can update it when you send me the form.
Best regards,
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
bethany.georgoulias@ncdenngov
512 N. Salisbury Street, Raleigh, NC 27604 (location)
1612 Mail Service Center, Raleigh, NC 27699-1612 (mailing)
Website: http//deg.nc.gov/about/divisions/energy-mineral-land-resources/stormwatgr
M1lORT!-! CAFiQLINA �
Department of Environmental 4uality
Email correspondence to and from this address is subject to the North
Carolina Public Records Law and may be disclosed to third parties.
From: Katy Breazeale <[e-mail]>
Sent: Wednesday, October 5, 2022 10:51 AM
To: Georgoulias, Bethany<[e-mail]>
Subject: [External] FW: Construction SW Permit Contact Information Update for NCC216034
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.

I appreciate the quick response. I should have asked this question as well — can you let me know how to change the
legally responsible individual? Christine Early is now the responsible part for Exeter Harper's Glen Developers,
LLC. Thanks again.
Katy Breazeale, CPA
CFO
Exeter Development Company
1905 Woodstock Rd
Suite 9250
Roswell, GA 30075
[e-mail]
[phone]
From: [e-mail] <[e-mail]>
Sent: Wednesday, October 5, 2022 10:45 AM
To: Jeffrey Smerko <[e-mail]>; [e-mail]; Katy Breazeale
<katy. [e-mail]>
Cc: [e-mail]; [e-mail]
Subject: Construction SW Permit Contact Information Update for NCC216034
This email is to notify you that contact information has been updated for Harper's Glen Subdivision, under COC No.
NCC216034. You can review the information in the permit folder in our Laserfiche Repository.
The following contact information is now associated with this permit record. If anything is in error, please contact
Bethany Georgoulias at [e-mail].
Legally Responsible Individual
Jeffrey Smerko
[e-mail]
9198182512
(Mailing Address) 1905 Woodstock Rd., #9250, Roswell, GA, 30075, United States
(Street Address) 1905 Woodstock Rd., #9250, Roswell, GA, 30075, United States
Site Contact
Walter Viele
(Organization) FSC 11, LLC dba Fred Smith Company
[e-mail]
919-524-1324
(Mailing Address) 701 Corporate Center Drive, Suite 101, Raleigh, NC, 27607, US
Billing Contact (if available)
[e-mail]
[phone]
This change was requested by: Katy Breazeale, CPA (CFO, Exeter Development Company) via e-mail on 10/5/2022.
Be sure to add [e-mail] to your contacts to avoid future a -mails about this application from going into
Spam filters.
The INC DEMLR Stormwater Program
512 N. Salisbury Street, Archdale Building 6th Floor, 1612 Mail Service Center, Raleigh, NC 27699-1612

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