NCC201074_MODIFICATION Supporting Doc (LEG RESP CHANGE)_20230427

NCGO1 Legally Responsible Individual Change Form
Use this form when:
The person who is legally responsible for the permit has changed, but there is NO CHANGE in the project name
or ownership.
**If the project name has changed, or if the ownership of the project has changed, do NOT use this form.**
Instead,you must submit a new NCG01 electronic Notice of Intent(eNOI).
Directions:
Print this form, complete, scan and upload to the Construction Stormwater Permit MODIFICATION Form.
Then, mail the original form to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street,6'h Floor(Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM UNTIL YOUR MODIFICATION HAS BEEN REVIEWED AND ACCEPTED AS COMPLETE.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE(NOT DIGITAL) [40 CFR 122.22)
Certificate of Coverage(COC) Number:
Name of Project: Pr,-, r
Legally Responsible Organizational Entity: G-I h L.L
PREVIOUS Legally Responsible Individual: /I'lk J 4
NEW Legally Responsible Individual: r-
The following section is to be completed and signed by the NEW Legally Responsible Individual.
Per NC General Statute 143-215.6E(i), any person who knowingly makes any false statement, representation,
or certification in any application, record, report,plan, or other document filed or required to be maintained
under this Article or a rule implementing this Article. . . shall be guilty of a Class 2 misdemeanor which may
include a fine not to exceed ten thousand dollars($10,000).
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NCG01 Legally Responsible Individual Change Form
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE INOT DIGITAL) [40 CFR 122.221
Under penalty of law, i certify that(check all boxes to indicate your agreement):
Er I am the person responsible for the construction activities of this project,for satisfying the
requirements of this permit, and for any civil or criminal penalties incurred due to violations of this
permit.
if I will abide by all conditions of the NCG010000 General Permit and the approved Erosion and
Sediment Control Plan.
If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan)of the NCG010000 General Permit, I will nonetheless ensure that all conditions of
Part 11 of the permit are met on the project at all times.
iT I understand that coverage under this permit will constitute the permit requirements for the
discharge(s) and is enforceable in the same manner as an individual permit.
P� This form has been reviewed and is accurate and complete to the best of my knowledge.
*Signature: 9�c Date: 27 — C
Print Name of Signed: i-c-J J C.
Title: J51
Mailing Address: +73 0 C7 ,r(c P4r IG AJC 7-73'349
Street Address: 14-J O p O.,k (0- !e k 0 n 54 "VC 7-7-33 0
Email Address: „ (2Cr, o
Phone Number: 9 1 9 r j<d if 31 0
* IMPORTANT NOTE. This form must be signed by a responsible corporate officer that owns or operates the
construction activity,such as a president,secretary, treasurer, or vice president, or a manager that is
authorized in accordance with Part IV,Section B, Item (6)of the NCG010000 permit.
For more information on signatory requirements,see Part IV,Section B, Item (6)of the NCGO10000 permit.
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Georgoulias, Bethany
From: Jarvis, Connor <[e-mail]>
Sent: Thursday, April 27, 2023 11:30 AM
To: Georgoulias, Bethany
Cc: Powell, Charles Edwin; Tucker, Jon
Subject: [External] RE: Construction SW Modification Request - MORE INFO/FORM NEEDED
Attachments: nc190137 revision.pdf, nc201074 revision.pdf
CAUTION: External email. Do not click links or open attachments unless verified. Report suspicious emails with the Report Message
button located on your Outlook menu bar on the Home tab.
Hello Bethany,
Thank you for your support on these two permit modifications. Attached are their respective signed documentation. I
will mail these with an accompanying letterhead along with an additional permit modification for our nc191069 permit,
which will also be revised to list Jon as the responsible official.
Let us know how to aid with any follow up questions moving forward.
Best Regards,
Connor
Connor W.Jarvis
Environmental Manager
Pfizer Global Supply
4300 Oak Park Road
Sanford, NC 27330
0: 919.566.52101 C: 336.414.9348
flze ' Breakthroughs that change patients'lives
From: Georgoulias, Bethany<[e-mail]>
Sent:Thursday, April 20, 2023 10:45 AM
To:Jarvis, Connor<[e-mail]>
Cc: Powell, Charles Edwin <[e-mail]>;Tucker,Jon <[e-mail]>
Subject: [EXTERNAL] RE: Construction SW Modification Request- MORE INFO/FORM NEEDED
Same for the submittal for NCC190137
If you can send these my way, I can move forward with processing the requests. Otherwise we will have to reject them
and have you resubmit each with the uploaded form.
Thanks,
Bethany Georgoulias
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From: Georgoulias, Bethany
Sent:Thursday,April 20, 2023 10:33 AM
To: [e-mail]
Cc:[e-mail]; [e-mail]; [e-mail]
Subject: RE: Construction SW Modification Request- MORE INFO/FORM NEEDED
Importance: High
Good morning,
We are reviewing this modification request, but only the annual fee invoice was uploaded.
For a change in legally responsible person, we require the attached form to be completed and signed (and original
mailed in). You can send me a scanned copy in the meantime.
Also, for the site contact update, I also need the mailing address (or just let me know it's the same as Jon Tucker).
Thank you!
Addional Explanation
More information(e.g., new Sile Contact details). If lots are being added, please include specific lot numbers.
Three permit modifications are requested for this respective stormwater permit-
(I & 2) Since the permits initiation in 2020 the site contact and responsible individual have both changed_ I
new contacts are listed below:
Legally Responsible Person: Jan Tucker/ 919-566-4310/Jon.Tucker pflzer_corn
Site Contact (Authorized Responsible Person): Connor Jarvis/ 919-566-5210/Ccnnor_Jarvis pfizer_com
( ) Due to the changing in responsibility of this permit's ownership the payment communications for its 411/:
due date was not directly escalated from the division to the current site contact and a Notice of Deficiency v
issued due to late payment. A timely payment is now being coordinated_ It is respectrully requested that a d
date extension is provided to lift the Notice of Deficiency.
You must upload supporting documentation below. Do not upload E&SC Plans unless .spy
sheets are the only documentation with approval for revised acres of disturbance, etc_ (only ur
applicable sheets).
Far changes to the legally responsible individual, you must upl ad thisfarm_
Supporting Documentation
Upload Supporting Documentation(Revised E&SC Approval,Close-Oul Doc, etc.)
Upload
NCC 01074 Annual Fee Invoice_20260301 (002).pdf 788. 5KB
Musi be PDF format
Bethany Georgoulias(she/her)
Environmental Engineer,Stormwater Program
DEMLR Laserfiche Administrator
Division of Energy,Mineral,and Land Resources
N.C. Department of Environmental Quality
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919 707 3641 office
[e-mail]
512 N. Salisbury Street, Raleigh, NC 27604 (location)
1612 Mail Service Center, Raleigh, NC 27699-1612 (mailing)
Website: http://deq.nc.gov/about/divisions/energy-mineral-land-resources/stormwater
e:1�0- REQ:>
NORTH CAROLINA
Department of Environmental quality
Email correspondence to and from this address is subject to the North
Carolina Public Records Law and may be disclosed to third parties.
From: [e-mail]<[e-mail]>
Sent: Monday, April 17, 2023 11:11 AM
To: [e-mail]
Cc:[e-mail]; [e-mail]
Subject: [External] Construction SW Modification Request Received
CAUTION: External email. Do not click links or open attachments unless verified. Report suspicious emails with the Report Message
button located on your Outlook menu bar on the Home tab.
Thank you for submitting a Modification request for Pfizer Pharmaceuticals GTx2 Contractor Parking in Lee County,
Certificate of Coverage (COC) no. NCC201074.
Modification Reason:3 requested modifications: (1) Legally Responsible Individual changed (2) Site Contact changed (3)
Annual fee due date extention
Additional Details(if provided):Three permit modifications are requested for this respective stormwater permit:
(1 &2) Since the permit's initiation in 2020 the site contact and responsible individual have both changed.The new
contacts are listed below:
Legally Responsible Person:Jon Tucker/919-566-4310/[e-mail]
Site Contact(Authorized Responsible Person): Connor Jarvis/919-566-5210/[e-mail]
(3) Due to the changing in responsibility of this permit's ownership the payment communications for its 4/1/2023 due
date was not directly escalated from the division to the current site contact and a Notice of Deficiency was issued due to
late payment. A timely payment is now being coordinated. It is respectfully requested that a due date extension is
provided to lift the Notice of Deficiency.
If your submittal is accepted, you will receive e-mail confirmation. You will also be notified if additional information is
needed or if the modification request or documents cannot be accepted.
If you have any questions, please contact [e-mail].
Be sure to add [e-mail] to your contacts to avoid future e-mails about this application from
going into Spam filters.
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The NC DEMLR Stormwater Program
512 N. Salisbury Street, Archdale Building 6th Floor, 1612 Mail Service Center, Raleigh, NC 27699-1612
This email was automatically generated by Laserfiche. Please do not respond to this email address, as responses are not
monitored.
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