NCS000450_Permit Contact Update Request_20230616

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by Anonymous User 6/16/2023 2:43:35 PM (Permit Contact Update Request)
Approve by Joyce Sanford 7/26/2023 1:05:54 PM (Contact Update Review)
• The task was assigned to DEMLR SW Admin General.The due date is:July 28,2023 5:00 PM
6/16/2023 2:43:37 PM
• The task was assigned to Joyce Sanford by round robin distribution 6/16/2023 2:43:37 PM

pEQNPDES Stormwater Permit Contact Update
Request
Request Submitted
NPDES Permit Enter your NPDES stormwater permit number or Certificate of Coverage(COC)number.
Number* NCS000450
Begins with NCS,NCG,or NCGNE(no exposure)
Facility Name* Carrboro-Small MS4
(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
❑ Delegation of Signature Authority(DOSA)
❑ Permit Contact Update
Q Billing Contact Update
Q Facility Contact Update
7 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
Randy Dodd
E-mail Address* [e-mail]
Phone No.* 919-918-7341
Mailing Address* 301 W. Main Street, Carrboro, NC 27510
Physical Address If different than mailing address
....................................................................
Facility Contact Update
Provide new facility contact information
..................................................................................
This person should REPLACE the current facility contact.
This person should just be added as another facility contact.
New Contact Name* First and Last Name
Randy Dodd

E-mail Address* [e-mail]
Phone No.* 919-918-7341
Mailing Address* 301 W. Main Street, Carrboro, NC 27510
Physical Address If different than mailing address
Add another facility contact if needed by clicking the'Add'button below
Submitter's Name* Please enter your FIRST and LAST name
Debbie Shoffner
Phone Number* Please enter your phone number
919-918-7435
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
Ae6&e _FW(Per,
Date 6/16/2023
Questions? Contact [e-mail].

Review
Verify Permit No.* Revise permit number below if incorrect.
NCS000450