NCC200776_Contact Update Request_20240201

NCG01 Legally Responsible Individual Change Form
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, 61h 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 CFR 122.22]
Certificate of Coverage (COC) Number: NCC200776
Name of Project: CREEKSIDE PHASE 2
Legally Responsible Organizational Entity: VINEYARDS MANAGEMENT GROUP
PREVIOUS Legally Responsible Individual: CHAD ASTLE
NEW Legally Responsible Individual: DONALD THOMAS STAPLEY, PRESIDENT
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

NCG01 Legally Responsible Individual Change Form
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE(NOT DIGITAL) [40 CFR 122.22]
Under penalty of law, I certify that(check all boxes to indicate your agreement):
❑ X 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.
❑ X I will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
❑ X If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater
Pollution Prevention Plan) of the NCG010000 General Permit, I will nonetheless ensure that all
conditions of Part II of the permit are met on the project at all times.
❑ X 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.
❑ X This form has been reviewed and is accurate and complete to the best of my knowledge.
*Signature: Date: Aal�
Print Name of Sig led: DONALD THOMAS STAPLEY
Title: PRESIDENT
Mailing Address: 400 STONEY CREEK DRIVE, REIDSVILLE, NC 27320
Street Address: 400 STONEY CREEK DRIVE, REIDSVILLE, NC 27320
Email Address: [e-mail]
Phone Number: 336-349-9161
* 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: Tina Graska <[e-mail]>
Sent: Thursday, February 1, 2024 12:05 PM
To: Georgoulias, Bethany
Cc: Shalonda Lotharp
Subject: RE: [External] Fw: Renewal of License (NC Reference No. NCG01-2020-0776)
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.
Hi Bethany.
Vineyards Management Group is an existing entity and should remain on the permit.
If you have any additional questions, please let us know.
�� ROOTS
Tina Graska
Director of Licensing
Direct: [phone]
16479 Dallas Pkwy, Suite 600, Addison, TX 75001
www.rootsm .com
From: Georgoulias, Bethany<[e-mail]>
Sent:Thursday, February 1, 2024 7:26 AM
To:Tina Graska <[e-mail]>
Subject: RE: [External] Fw: Renewal of License (NC Reference No. NCG01-2020-0776)
Tina,just to verify—is Vineyard Management Group an old name of the same company, or has the project changed
ownership?
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: httl2://deq.nc.gov/about/divisions/energy-mineral-land-resources/stormwater
From:Tina Graska <[e-mail]>
Sent:Tuesday,January 30, 2024 5:21 PM
1

To: Georgoulias, Bethany<[e-mail]>; Shalonda Lotharp<Shalonda.Lotharp@ roots mg.com>
Subject: RE: [External] Fw: Renewal of License (NC Reference No. NCG01-2020-0776)
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.
Hi Bethany.
I have attached the Legally Responsible Change Form signed by our President, Donald Thomas Stapley. Chad Astle is no
longer with the company.
Please let Shalonda and I know if you will require any additional information in processing the form. I also updated the
mailing address on the form as the address currently on it is for a mailbox at a UPS store and I am unclear who would be
checking that mail.
Thank you for your assistance.
& ROOTS
Tina Graska
Director of Licensing
Direct: [phone]
16479 Dallas Pkwy, Suite 600, Addison, TX 75001
www.rootsm .com
From: Shalonda Lotharp <[e-mail]>
Sent:Wednesday,January 10, 2024 9:55 AM
To:Tina Graska <[e-mail]>;Tishanna Newman <[e-mail]>;Tricia Shannon
<[e-mail]>;Andrea Sherman <[e-mail]>;Tom Stapley
<Tom.Sta pley@ rootsmg.com>
Subject: Fw: [External] Fw: Renewal of License (NC Reference No. NCG01-2020-0776)
To whom it may concern can someone please tell me who would get this changed.
Thanks,
Shalonda
Shalonda Lotharp
eA)) Regional Manager of NC/SC/GA
ROOTS
m: 336.520.0976
2

RootsMG.com e: shalonda.LotharpCa)roots mg.com
16470 Dallas Pkwy, Ste. 600
Addison, TX 75001
12t
MAL H9USING
OPPORTUNTY
From: Georgoulias, Bethany<[e-mail]>
Sent:Wednesday,January 10, 2024 11:48 AM
To: Shalonda Lotharp<[e-mail]>
Cc: Chad Astle<[e-mail]>; [e-mail] <[e-mail]>
Subject: RE: [External] Fw: Renewal of License (NC Reference No. NCG01-2020-0776)
Good morning,
To update the legally responsible person for this permit(held by Vineyards Management Group), the form attached
must be filled out and returned to us. It can be scanned and emailed, but the original signed hard copy must be mailed
to our office. Please 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 8, Item (6)of the NCGO10000 permit.
If you need to review the permit COC and associated documents, please check the NCC200776 Permit COC folder in our
repository.
Best regards,
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: Shalonda Lotharp <[e-mail]>
Sent:Wednesday,January 10, 2024 10:56 AM
To: Georgoulias, Bethany<[e-mail]>
Subject: [External] Fw: Renewal of License (NC Reference No. NCG01-2020-0776)
3

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.
Shalonda Lotharp
6) Regional Manager of NC/SC/GA
ROOTS
m: 336.520.0976
RootsMG.com e: shalonda.Loth arpCabrootsmg.com
16470 Dallas Pkwy, Ste. 600
Addison, TX 75001
12t
MAL H9USINC
0PPDHTUII17V
From: Shalonda Lotharp <[e-mail]>
Sent:Wednesday,January 10, 2024 10:51 AM
To: [e-mail]<[e-mail]>; [e-mail]
<[e-mail]>
Cc:Teshia Fields<[e-mail]>
Subject: Renewal of License (NC Reference No. NCG01-2020-0776)
To whom it may concern: My name is Shalonda Lotharp I am Regional over Creekside and I need the
information for the license NCC200776 email or letter please sent to me at Creekside Mobile Home Park
at 400 Stoney Creek Dr Reidsville NC 27320 and 16479 Dallas Pkwy Suite 600,Addison,TX 75001. 1 would
greatly appreciate this change Chad Astle is no longer with the company. I hope this email finds you well.
I look forward to hearing from you.
Sincerely,
Shalonda
4

AL
Shalonda Lotharp
LOA) Regional Manager of NC/SC/GA
ROOTS
m: 336.520.0976
RootsMG.com e: shalonda.LotharpCd)roots mg.com
16470 Dallas Pkwy, Ste. 600
Addison, TX 75001
12t
MAL H94SINC
0 R PD ULM ITT
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.
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