NCG210028_Permit Contact Update Request_20230207

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 2/7/2023 1:48:25 PM (Permit Contact Update Request)
Approve by Joyce Sanford 3/17/2023 1:03:34 PM (Contact Update Review)
• The task was assigned to DEMLR SW Admin General. The due date is: March 21, 2023 5:00 PM
2/7/2023 1:48:40 PM
• The task was assigned to Kieu Tran by round robin distribution 2/7/2023 1:48:40 PM
• Kieu Tran reassigned the task to Joyce Sanford 3/14/2023 2:41:12 PM

Request Submitted
NPDES Permit Enter your NPDES stormwater permit number or Certificate of Coverage (COC) number.
Number* NCG210028
Begins with NCS, NCG, or NCGNE (no exposure)
Facility Name* Baxter Healthcare
(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
DEREK BOUCHARD
E-mail Address* [e-mail]
Phone No.* 8287566644
Mailing Address* 65 Pitts Station Rd
Marion, NC 28752
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
DEREK BOUCHARD
E-mail Address* [e-mail]
Phone No.*
Mailing Address*
8287566644
65 Pitts Station Rd
Marion, NC 28752
Physical Address If different than mailing address
Person(s) with Delegation of Signature Authority (DOSA)
Delegation of Please upload the signed "Stormwater Permit Delegation of Signature Authority Form"
Signature Authority SW NCG210028 DoSA 26Jan23.pdf 147.79KB
pdf only
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
DEREK BOUCHARD
E-mail Address* [e-mail]
Phone No.*
Mailing Address*
8287566644
65 Pitts Station Rd
Marion, NC 28752
Physical Address If different than mailing address
Add another facility 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 Retain Brian Valiquette and Stephen Gouge as authorized signees, replace all
another contact instances of Corey Carpentier, Andrea Dorsey, Amanda Shepard, and Tony Leopard
update: * with Derek Bouchard.
Submitter's Name* Please enter your FIRST and LAST name
Derek Bouchard
Phone Number* Please enter your phone number
8287566644
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 2/7/2023
Questions? Contact [e-mail].

Review
Verify Permit No.* Revise permit number below if incorrect.
NCG210028