NCG210450_Permit Contact Update Request_20230818

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by Anonymous User 8/18/2023 1:48:20 PM (Permit Contact Update Request)
Approve by Joyce Sanford 9/22/2023 5:01:50 PM (Contact Update Review)
• The task was assigned to DEMLR SW Admin General.The due date is: September 29,2023 5:00 PM
8/18/2023 1:48:25 PM
• The task was assigned to Joyce Sanford by round robin distribution 8/18/2023 1:48:25 PM

DEQIwo NPDES Stormwater -Request
Request Submitted
NPDES Permit Enter your NPDES stormwater permit number or Certificate of Coverage(COC)number.
Number* NCG210450
Begins with NCS,NCG,or NCGNE(no exposure)
Facility Name* Enviva Pellets Sampson, LLC
(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
Owner Affiliation (Legally Responsible Individual) Change
Upload a copy of the completed and signed Permit Owner Affiliation Designation Form below.We can begin making
updates with this submittal, but please note that you must mail in the original signed copy to our office,in
accordance with requirements in 40 CFR 122.22.
Staff may contact you to confirm the requested change if this Owner is also associated with other permits in our system.
Changes to Owner Affiliation affect all permits tied to that Owner.
Owner Affiliation Please upload the signed"Permit Owner Affiliation Designation Form"
Change Form Upload Permit Owner Affliation Designation Form-Wearley
521.06KB
vAU G 172023.pdf
pdf only
Permit Contact Update
Provide new permit contact information
This person should REPLACE the current permit contact.
This person should just be added as another permit contact.
New Contact Name* First and Last Name
Rob Niska
E-mail Address* [e-mail]
Phone No.* 910-465-0298
Mailing Address* 5 Connector Rd US117
Faison, NC 28341

Physical Address If different than mailing address
This person should REPLACE the current permit contact.
This person should just be added as another permit contact.
New Contact Name* First and Last Name
Joshua Wearley
E-mail Address* [e-mail]
Phone No.* 260-750-0424
Mailing Address* 5 Connector Rd US117
Faison, NC 28341
Physical Address If different than mailing address
......... ......... ......... .........
Add another permit contact if needed by clicking the'Add'button below
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
Accounts Payable
E-mail Address* [e-mail]
Phone No.* 301-657-5560
Mailing Address* ATTN:Accounts Payable
7272 Wisconsin Avenue Suite 1800
Bethesda Maryland 20814
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 Stormwater DOSA-Belcher&Niska
777.04KB
vAUG 172023.pdf
pdf only
...................
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
Chris Belcher

E-mail Address* [e-mail]
Phone No.* 984-344-4732
Mailing Address* 5 Connector Rd US117
Faison, NC 28341
Physical Address If different than mailing address
Add another facility contact if needed by clicking the'Add'button below
Other Contact Updates
Only use this section if none of the categories above apply.
Provide details about N/A
another contact
update:*
Submitter's Name* Please enter your FIRST and LAST name
Rob Niska
Phone Number* Please enter your phone number
910-465-0298
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
fr°f`AA#A
Date 8/18/2023
Questions? Contact [e-mail].

Review
Verify Permit No.* Revise permit number below if incorrect.
NCG210450