NCC210566_Contact Update Request (Address Only)_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, 6eh 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: NrC C f (-] J62
Name of Project: _ 0. C C
Legally Responsible Organizational En lty: <--
PREVIOUS Legally Responsible Individual:
NEW Legally Responsible Individual:
The following section is to be completed and signed by the NEW Legally Responsible Individual.
Per NC General Statute 143-215.6B(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).
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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):
I am the person responsible for the construction activities of this project,for satisfying the
i. requirements of this permit, and for any civil or criminal penalties incurred due to violations of this
permit.
I will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
If the approved Erosion and Sediment Control Plan is not compliant with Part II (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.
IZ 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.
*Signature: Date:
Print Name of Signed:
Title: V
Mailing Address: 0 . CMG x c 9
Street Address: J4
rr� N C '� t�C • ' [
Email Address: k't"D t.CS4-e IY1 •r r�{a( t;�C
Phone Number: 3 :j(c 1 (D ` 50
*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 NCG010000 permit.
For more information on signatory requirements,see Part IV,Section B, Item(6)of the NCGO10000 permit.
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Georgoulias, Bethany
From: Kristin Foust <[e-mail]>
Sent: Thursday, February 1, 2024 3:23 PM
To: Georgoulias, Bethany
Cc: Holloman, Tevye L
Subject: Re: [External] Re: Construction Stormwater Permit Annual Fee - NCC210566
Attachments: COC Change of Address Form.pdf
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.
Thanks so much, please find the form attached. Original will be mailed.
From: Georgoulias, Bethany<[e-mail]>
Sent:Thursday, February 1, 2024 10:32 AM
To: Kristin Foust<[e-mail]>
Cc: Holloman,Tevye L<[e-mail]>
Subject: RE: [External] Re: Construction Stormwater Permit Annual Fee- NCC210566
This form should be filled out and signed. It's helpful to note that it's just for an address update to the individual if the
person is staying the same. You can scan the signed copy and email it to me, but please be sure to send in the original
signed copy.
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/stormwatgr
From: Kristin Foust<[e-mail]>
Sent:Thursday, February 1, 2024 10:23 AM
To: [e-mail]
Cc: Georgoulias, Bethany<[e-mail]>; Holloman,Tevye L<[e-mail]>
Subject: [External] Re: Construction Stormwater Permit Annual Fee- NCC210566
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.
Thanks, please advise what is process of changing address of legally responsible person on permit?
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From: [e-mail]<[e-mail]>
Sent:Thursday, February 1, 2024 4:05 AM
To: Kristin Foust<[e-mail]>
Cc: Kristin Foust<[e-mail]>; Kristin Foust<[e-mail]>;
[e-mail]<bethany.georgoulias@ deg.nc.gov>;[e-mail]
<[e-mail]>
Subject: Construction Stormwater Permit Annual Fee- NCC210566
Attached is the 2024 annual fee invoice for your Construction Stormwater NPDES permit, COC no. NCC210566. When
using the ePayment website (https://www.deg.nc.gov/sw-epayments), be sure to enter ONLY the COC permit number
(not the invoice number with "-2024" after it). Please contact Tev Holloman at [e-mail] with any
questions.
If this project has been closed out,you must submit a Notice of Termination (NOT) request here:
https://edocs.deg.nc.gov/Forms/NCG01-Termination
Permittee: SGRM, Inc.
Project Name: Heritage Glen - Phase 5C
Project Location:Village of Alamance
County:Alamance
Please note that effective October 3, 2023, the annual fee for this general permit has increased to$120.
Sincerely,
The DEMLR Stormwater Program
This email was automatically generated by Laserfiche. Please do not respond to this email address, as responses are not
monitored.
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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