NCG110150_Permit Contact Update Request_20230427

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by Anonymous User 4/27/2023 2:02:58 PM (Permit Contact Update Request)
Approve by Joyce Sanford 5/11/2023 3:17:53 PM(Contact Update Review)
• The task was assigned to DEMLR SW Admin General.The due date is:June 8,2023 5:00 PM
4/27/2023 2:03:03 PM
• The task was assigned to Joyce Sanford by round robin distribution 4/27/2023 2:03:03 PM

pEQNPDES Stormwater Permit Contact Update
Request
Request Submitted
NPDES Permit Enter your NPDES stormwater permit number or Certificate of Coverage(COC)number.
Number* NCG110150
Begins with NCS,NCG,or NCGNE(no exposure)
Facility Name* Wallace Regional WWTP
(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 J Owner Affiliation(Legally Responsible Individual)Update
*
apply: ❑ Permit Ownership Transfer or Facility Name Change
Q Delegation of Signature Authority(DOSA)
❑ Permit Contact Update
Q Billing Contact Update
❑ Facility Contact Update
Tj Other Contact Update
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
Joseph Trollinger
E-mail Address* [e-mail]
Phone No.* 910-285-4136
Mailing Address* 316 E. Murray St
Wallace INC 28466
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 signature authority for Inyoung Seo.pdf 154.14KB
pdf only

Other Contact Updates
Only use this section if none of the categories above apply.
Provide details about Owner Contact Person-remove Laurence Bergman's information and replace with
another contact Robert Taylor,Jr,Town manager, [e-mail],910-285-4136
update:*
Submitter's Name* Please enter your FIRST and LAST name
Lisa Cottle
Phone Number* Please enter your phone number
910-665-2091
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 4/27/2023
Questions? Contact [e-mail].

Review
Verify Permit No.* Revise permit number below if incorrect.
NCG110150