NCS000294_Permit Contact Update Request_20221021

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 10/21/2022 10:26:48 AM (Permit Contact Update Request)
Approve by Tran, Kieu M 10/21/2022 2:10:13 PM (Contact Update Review)
• The task was assigned to Tran, Kieu M. The due date is: December 2, 2022 5:00 PM
10/21/2022 10:27 AM

Request Submitted
NPDES Permit Enter your NPDES stormwater permit number or Certificate of Coverage (COC) number.
Number* NCS000294
Begins with NCS, NCG, or NCGNE (no exposure)
Facility Name* Southern States Coop - Creedmoor
(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
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
Jennifer Bunting
E-mail Address* [e-mail]
Phone No.*
804-281-1189
Mailing Address*
6606 West Broad St
Richmond, VA 23230
Physical Address
If different than mailing address
6606 West Broad St
Richmond, VA 23230
Add another permit 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 1) Add Jennifer Bunting as a Permit Contact (in addition to Zach Garlick).
another contact
update: * 2) Replace John R Madden with Jennifer Bunting as the Owner Contact.
3) Update the Owner Affiliation and Facility Contact addresses (Jennifer Bunting).
These addresses need to be changed to:
6606 West Broad St
Richmond, VA 23230
Submitter's Name* Please enter your FIRST and LAST name
Zachary Garlick
Phone Number* Please enter your phone number
3364204853
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 10/21 /2022
Questions? Contact [e-mail].

Review
Verify Permit No.* Revise permit number below if incorrect.
NCS000294