NCG080063_Permit Contact Update Request_20221014

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 10/14/2022 10:27:56 AM (Permit Contact Update Request)
Approve by Tran, Kieu M 10/14/2022 3:40:47 PM (Contact Update Review)
• The task was assigned to Tran, Kieu M. The due date is: November 25, 2022 5:00 PM
10/14/2022 10:28 AM

Request Submitted
NPDES Permit Enter your NPDES stormwater permit number or Certificate of Coverage (COC) number.
Number* NCG080063
Begins with NCS, NCG, or NCGNE (no exposure)
Facility Name* City of Charlotte Fleet Management
(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
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
Andrew DeCristofaro
E-mail Address* [e-mail]
Phone No.* 7045178771
Mailing Address* 600 E 4th St
14th Floor
Charlotte, NC 28202
Physical Address If different than mailing address
Facility Contact Update
Provide new facility contact information
This person should REPLACE the current facility contact.
This person should just be added as another facility contact.

New Contact Name * First and Last Name
Kenneth Bonham
E-mail Address* [e-mail]
Phone No.* 7046073125
Mailing Address* 900 W 12th St
Charlotte, NC 28206
Physical Address If different than mailing address
.......................................................................................................................................................................................................................
Add another facility contact if needed by clicking the 'Add' button below
Other Contact Updates
Only use this section if none of the categories above apply.
Provide details about Please remove Kristen A O'Reilly from both Permit Contact Persons and Persons
another contact with Delegated Signatory Authority
update: *
Submitter's Name* Please enter your FIRST and LAST name
Andrew DeCristofaro
Phone Number* Please enter your phone number
7045178771
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 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
Date
AN" P"sTPP14 r0
10/14/2022
Questions? Contact [e-mail].

Review
Verify Permit No.* Revise permit number below if incorrect.
NCG080063