NCC213764_Contact Update Request_20230706

Legally ResponsibleIndividual r
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, 6th 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 CIFIR 122.22]
Certificate of Coverage (COC) Number: 6,L—Z 3,S toge,
Name of Project: iJLac�fj���r 160
Legally Responsible Organizational Entity: ZAO , P LLc
PREVIOUS Legally Responsible Individual: ) C. I
NEW Legally Responsible Individual: 014 "
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).
Page 1 of 2

Legally Responsible Individual r
THE FORM O IL MUST RE COMPLETED WITH AN ORIGINAL SIGNATURE(NOTDIGITAL) [40 CFR 122
Under penalty of law, I certify that (check all boxes to indicate your agreement):
C ' 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.
L I will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
C If the approved Erosion and Sediment Control Plan is not compliant with Part 11 (Stormwater Pollution
Prevention Plan)of the NCGO10000 General Permit, I will nonetheless ensure that all conditions of
Part II of the permit are met on the project at all times.
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.
® This form has been reviewed and is accurate and complete to the best of my knowledge.
r
*Signature: Date:
Print Name of Signed: (
Title: P10,560 f cst c-0 T
Mailing Address: ()1 /I/l' V1 t rS 6 I'f Pde t G°��S(� BC1 , ' A(�[ r
Street Address: .301 Gar crCr/�~ r►ls- t 5:r-0% 1691, C
Email Address: ,y� t ire 5 j d �
Phone Number: 6 q6 - Z 3 166
* 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 NCGO10000 permit.
For more information on signatory requirements,see Part IV, Section B, Item (6)of the NCGO10000 permit.
Page 2 of 2

Georgoulias, Bethany
From: John Osinga <[e-mail]>
Sent: Thursday, July 6, 2023 3:27 PM
To: Georgoulias, Bethany
Cc: Holloman, Tevye L
Subject: RE: [External] Construction Stromwater Permit Annual Fee- NCC213764 - Leg Resp
Change form
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.
Can I have site contact updated to Chris Robusto Vice President of Land, email [e-mail],
301 McCullough Drive, Ste, 109 Charlotte, NC 28262, 704-574-0316
John Osinga
Land Acquisition Analyst
(( Dream Finders Homes
1�.
RE AM�lOEI COMES a: 301 McCullough Drive, Ste. 109, Charlotte, NC 28262
■ m o: 434.426.8049
e: johnosinga(a�dreamfindershomes.com
Official Hon Builderof Ow PGA TOUR w:www.dreamfindershomes.com
�W
From: Georgoulias, Bethany<[e-mail]>
Sent:Thursday,July 6, 2023 3:19 PM
To:John Osinga <[e-mail]>
Cc: Holloman,Tevye L<[e-mail]>
Subject: RE: [External] Construction Stromwater Permit Annual Fee- NCC213764- Leg Resp Change form
Caution: CAUTION:This email originated from outside of the organization. Do not click links or open attachments
unless you recognize the sender and know the content is safe.
Hi,John,
I am working on making updates this week. The form included Dan Zalinsky's information.
For site contact updates, I still need Chris Robusto's title, mailing address(orjust let me know it's the same as the
legally responsible if that's the case), and phone number.
Thank you,
Bethany Georgoulias (she/her)
Environmental Engineer, Stormwater Program
DEMLR Laserfiche Administrator
Division of Energy, Mineral,and Land Resources
i

N.C. Department of Environmental Quality
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
From:John Osinga <[e-mail]>
Sent:Wednesday,July 5, 2023 11:31 AM
To: Georgoulias, Bethany<[e-mail]>
Cc: Holloman,Tevye L<[e-mail]>
Subject: RE: [External] Construction Stromwater Permit Annual Fee- NCC213764- Leg Resp Change form
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.
Please see attached.
Best,
John Osinga
Land Acquisition Analyst
Dream Finders Homes
DREAM FINDERS a: 301 McCullough Drive, Ste. 109, Charlotte, NC 28262
■ o: 434.426.8049
e: lohnosinga(a�dreamfindershomes.com
Official-Ron Builder of ft PEA TOUR w:www.dreamfindershomes.com
OR 0 m0ok a 0
From: Georgoulias, Bethany<[e-mail]>
Sent:Wednesday,July 5, 2023 8:36 AM
To:John Osinga <[e-mail]>
Cc: Holloman,Tevye L<[e-mail]>
Subject: RE: [External] Construction Stromwater Permit Annual Fee- NCC213764- Leg Resp Change form
Importance: High
Caution: CAUTION:This email originated from outside of the organization. Do not click links or open attachments
unless you recognize the sender and know the content is safe.
Good morning,
Yes, we can update those contacts. Thanks for alerting us.
For a change in Legally responsible person, we need the attached form completed and returned to us first. You can scan
the copy and email it to me, but the original signed hard copy needs to be mailed in (This is to meet federal
requirements for the permit).
2

For site contact updates, I also need Chris Robusto's title, mailing address(or just let me know it's the same as the
legally responsible if that's the case), and phone number.
Thank you,
Bethany Georgoulias (she/her)
Environmental Engineer, Stormwater Program
DEMLR Laserfiche Administrator
Division of Energy, Mineral,and Land Resources
N.C. Department of Environmental Quality
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
From:John Osinga <[e-mail]>
Sent:Wednesday,July 5, 2023 8:22 AM
To: [e-mail]
Cc: Georgoulias, Bethany<[e-mail]>; Holloman,Tevye L<[e-mail]>
Subject: [External] Construction Stromwater Permit Annual Fee- NCC213764
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 All,
I received this email from Chris Granelli. Could I please have this form updated?We have had some turnover in the
office and now we have new contacts.
Can I please have the "Legally Responsible Person" Changed to Dan Zalinsky, our new Divisional President. Email
[e-mail] telephone number 646-210-3760
Can I have site contact updated to Chris Robusto, email [e-mail]
Best,
John Osinga
Land Acquisition Analyst
Dream Finders Homes
a: 301 McCullough Drive, Ste. 109, Charlotte, NC 28262
DREAM FINDERS tliS m o: 434.426.8049
e: lohnosinga(a)dreamfindershomes.com
Offidai Horm BuiWerof Ow i TOUR w:www.dreamfindershomes.com
0
3

Disclaimer
The information contained in this communication from the sender is confidential. It is intended solely for use by the recipient and
others authorized to receive it. If you are not the recipient, you are hereby notified that any disclosure, copying, distribution or
taking action in relation of the contents of this information is strictly prohibited and may be unlawful.
This email has been scanned for viruses and malware, and may have been automatically archived by Mimecast, a leader in email
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Email correspondence to and from this address may be subject to the North Carolina Public Records Law and may be disclosed to third parties by an authorized
state official.
Disclaimer
The information contained in this communication from the sender is confidential. It is intended solely for use by the recipient and
others authorized to receive it. If you are not the recipient, you are hereby notified that any disclosure, copying, distribution or
taking action in relation of the contents of this information is strictly prohibited and may be unlawful.
This email has been scanned for viruses and malware, and may have been automatically archived by Mimecast, a leader in email
security and cyber resilience. Mimecast integrates email defenses with brand protection, security awareness training, web security,
compliance and other essential capabilities. Mimecast helps protect large and small organizations from malicious activity, human
error and technology failure; and to lead the movement toward building a more resilient world. To find out more, visit our website.
Disclaimer
The information contained in this communication from the sender is confidential. It is intended solely for use by the recipient and
others authorized to receive it. If you are not the recipient, you are hereby notified that any disclosure, copying, distribution or
taking action in relation of the contents of this information is strictly prohibited and may be unlawful.
This email has been scanned for viruses and malware, and may have been automatically archived by Mimecast, a leader in email
security and cyber resilience. Mimecast integrates email defenses with brand protection, security awareness training, web security,
compliance and other essential capabilities. Mimecast helps protect large and small organizations from malicious activity, human
error and technology failure; and to lead the movement toward building a more resilient world. To find out more, visit our website.
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