NCG110048_Permit Contact Update Request_20230601

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by Anonymous User 6/1/2023 10:08:08 AM (Permit Contact Update Request)
Approve by Joyce Sanford 6/2/2023 1:47:33 PM (Contact Update Review)
• The task was assigned to DEMLR SW Admin General.The due date is:July 13,2023 5:00 PM
6/1/2023 10:08:12 AM
• The task was assigned to Joyce Sanford by round robin distribution 6/1/2023 10:08:12 AM

DEQIwo NPDES Stormwater -Request
Request Submitted
NPDES Permit Enter your NPDES stormwater permit number or Certificate of Coverage(COC)number.
Number* NCG110048
Begins with NCS,NCG,or NCGNE(no exposure)
Facility Name* Mason Farm 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 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
Other Contact Updates
Only use this section if none of the categories above apply.
Provide details about in the Owner Contact Person list Ed Kerwin and Monica Dodson.They both need to
another contact be removed.Wilmer Anthony Lawson should be list in the Owner Contact Person.
update:*
Submitter's Name* Please enter your FIRST and LAST name
Wilmer Lawson
Phone Number* Please enter your phone number
9195374351
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 6/1/2023
Questions? Contact [e-mail].

Review
Verify Permit No.* Revise permit number below if incorrect.
NCG 110048