NCG070189_Permit Contact Update Request_20230517

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by Anonymous User 5/17/2023 12:32:54 PM (Permit Contact Update Request)
Approve by Joyce Sanford 5/22/2023 11:17:12 AM (Contact Update Review)
• The task was assigned to DEMLR SW Admin General.The due date is:June 28,2023 5:00 PM
5/17/2023 12:33:00 PM
• The task was assigned to Joyce Sanford by round robin distribution 5/17/2023 12:33:00 PM

DEQIwo NPDES Stormwater -Request
Request Submitted
NPDES Permit Enter your NPDES stormwater permit number or Certificate of Coverage(COC)number.
Number* NCG070189
Begins with NCS,NCG,or NCGNE(no exposure)
Facility Name* Plycem Allura
(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
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
Jason Jordan
E-mail Address* [e-mail]
Phone No.* 835-615-2944
Mailing Address* 1149 ABTCO Road
North Wilkesboro, NC 28659
Physical Address If different than mailing address
Submitter's Name* Please enter your FIRST and LAST name
Kim Burton
Phone Number* Please enter your phone number
336-466-5309
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 ����77
,Xme vW
Date 5/17/2023
Questions? Contact [e-mail].

Review
Verify Permit No.* Revise permit number below if incorrect.
NCG070189