NCG080776_Permit Contact Update Request_20221219

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 12/19/2022 10:40:16 AM (Permit Contact Update Request)
Approve by Kieu Tran 3/8/2023 12:10:28 PM (Contact Update Review)
• The task was assigned to DEMLR SW Admin General. The due date is: January 30, 2023 5:00 PM
12/19/2022 10:40:25 AM
• The task was assigned to Kieu Tran by round robin distribution 12/19/2022 10:40:25 AM

Request Submitted
NPDES Permit Enter your NPDES stormwater permit number or Certificate of Coverage (COC) number.
Number* NCG080776
Begins with NCS, NCG, or NCGNE (no exposure)
Facility Name* City of Durham Public Works Operations Center
(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
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
John Sandin
E-mail Address* [e-mail]
Phone No.* 9193160031
Mailing Address* 1100 Martin Luther King Jr. Pkwy
Durham. NC 27707
Physical Address If different than mailing address
1100 Martin Luther King Jr. Pkwy
Durham, NC 27707
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
Jim Azarelo
E-mail Address* [e-mail]
Phone No.* 9199950400

Mailing Address*
Physical Address
101 City Hall Plz
Suite 3100
Durham. NC 27701
If different than mailing address
101 City Hall Plz
Suite 3100
Durham, NC 27701
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
Terrence King
E-mail Address* [e-mail]
Phone No.* 9195604312
Mailing Address* 1100 Martin Luther King Jr. Pkwy
Durham, NC 27707
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
Jim Azarelo
Phone Number* Please enter your phone number
9199950400
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
#W7fswr
12/19/2022
Questions? Contact [e-mail].

Review
Verify Permit No.* Revise permit number below if incorrect.
NCG080776