NCG120054_Permit Contact Update Request_20221212 (2)

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 12/12/2022 12:10:24 PM (Permit Contact Update Request)
Approve by Kieu Tran 12/15/2022 1:54:06 PM (Contact Update Review)
• The task was assigned to Kieu Tran by round robin distribution 12/12/2022 12:10 PM
The task was assigned to DEMLR SW Admin General. The due date is: January 23, 2023 5:00 PM
12/12/2022 12:10 PM

Request Submitted
NPDES Permit Enter your NPDES stormwater permit number or Certificate of Coverage (COC) number.
Number* NCG120054
Begins with NCS, NCG, or NCGNE (no exposure)
Facility Name* Sampson County Disposal LLC Landfill
(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
Person(s) with Delegation of Signature Authority (DOSA)
Delegation of Please upload the signed "Stormwater Permit Delegation of Signature Authority Form"
Signature Authority EW-DOSA-Form Signed.pdf 191.89KB
pdf only
Submitter's Name* Please enter your FIRST and LAST name
Matthew M. Jones
Phone Number* Please enter your phone number
9198280577x153
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 12/12/2022
Questions? Contact [e-mail].

Review
Verify Permit No.* Revise permit number below if incorrect.
N CG 120054