NCG160166_Permit Contact Update Request_20221216

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 12/16/2022 9:42:57 AM (Permit Contact Update Request)
Approve by Kieu Tran 12/16/2022 12:00:57 PM (Contact Update Review)
• The task was assigned to Kieu Tran by round robin distribution 12/16/2022 9:43 AM
The task was assigned to DEMLR SW Admin General. The due date is: January 27, 2023 5:00 PM
12/16/2022 9:43 AM

Request Submitted
NPDES Permit Enter your NPDES stormwater permit number or Certificate of Coverage (COC) number.
Number* NCG160166
Begins with NCS, NCG, or NCGNE (no exposure)
Facility Name* Mount Airy Asphalt Plant
(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 Upload Permit Owner Designation Form.pdf 715KB
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
Cody Luper
E-mail Address* [e-mail]
Phone No.* [phone]
Mailing Address* 4193 Old Route 100 Rd, Pulaski, VA 24301
Physical Address If different than mailing address

Add another permit contact if needed by clicking the 'Add' button below
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
Account Payable
E-mail Address* [e-mail]
Phone No.* [phone]
Mailing Address* P.O. Box 12627, Roanoke, VA 24027
Physical Address If different than mailing address
523 Rutherford Ave., N.E. Roanoke, VA 24027
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
Jonathan Lane
E-mail Address* [e-mail]
Phone No.* [phone]
Mailing Address* 381 Quarry Road, Mount Airy, NC 27030
Physical Address If different than mailing address
Add another facility contact if needed by clicking the 'Add' button below
Submitter's Name* Please enter your FIRST and LAST name
Cody Luper
Phone Number* Please enter your phone number
[phone]
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
6'�� �5 &tee
Date 12/16/2022
Questions? Contact [e-mail].

Review
Verify Permit No.* Revise permit number below if incorrect.
NCG160166