NCG110042_Permit Contact Update Request Record_20221110

Georgoulias, Bethany
From: [e-mail]
Sent: Thursday, November 10, 2022 1:15 PM
To: Lockhart, Allen
Cc: Tran, Kieu M; Georgoulias, Bethany
Subject: Permit Contact Update Request for NCG110042
Unfortunately we cannot process the Permit Contact Update Request for permit no. NCG110042 submitted
on 11/8/2022 any further. A Stormwater Program staff member will be in touch with more information.
Comments during review: Permit contact and billing contact has been updated. Please use the correct Owner Affiliation
form and upload it again. Click on the blue hyperlink, titled "Permit Owner Affiliation Designation Form," which is
located under the "Owner Affiliation (Legally Responsible Individual) Change."
Please contact Kieu Tran at [e-mail] with any questions.
The NC DEMLR Stormwater Program

NPDES Permit Enter your NPDES stormwater permit number or Certificate of Coverage (COC) number.
Number* NCG110042
Begins with NCS, NCG, or NCGNE (no exposure)
Facility Name* Roxboro WWTP
(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 NPDES SW Permit Summary Report 11 4 22.pdf 510.81 KB
Upload* 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
Allen Lockhart
E-mail Address* [e-mail]
Phone No.* 3365830224
Mailing Address* PO Box 128
Roxboro, NC 27573
Physical Address If different than mailing address
105 South Lamar Street
Roxboro. NC 27573

Add another permit contact if needed by clicking the 'Add' button below
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
Derek Clayton
E-mail Address* [e-mail]
Phone No.*
3363226000
Mailing Address*
PO Box 128
Roxboro, NC 27573
Physical Address
If different than mailing address
902 Cavel-Chub Lake Road
Roxboro, NC 27574
Submitter's Name*
Please enter your FIRST and LAST name
Allen Lockhart
Phone Number*
Please enter your phone number
3363226010
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
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11 /8/2022
Questions? Contact [e-mail].