NCS000201_Permit Contact Update Request_20240123

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by Anonymous User 1/23/2024 11:14:05 AM (Permit Contact Update Request)
Approve by Joyce Sanford 3/1/2024 10:57:15 AM (Contact Update Review)
• The task was assigned to DEMLR SW Admin General.The due date is: March 5,2024 5:00 PM
1/23/2024 11:14:09 AM
• The task was assigned to Joyce Sanford by round robin distribution 1/23/2024 11:14:09 AM

DEQIwo NPDES Stormwater -Request
Request Submitted
NPDES Permit Enter your NPDES stormwater permit number or Certificate of Coverage(COC)number.
Number* NCS000201
Begins with NCS,NCG,or NCGNE(no exposure)
Facility Name* UNC Ch-Hazardous Mat Facility
(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
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
Douglas Benjamin
E-mail Address* [e-mail]
Phone No.* 9194450940
Mailing Address* 1120 Estes Dr, CB 1650,Chapel Hill, NC 27599-1650
Physical Address If different than mailing address
1120 Estes Dr, Chapel Hill, NC 27599
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 The linked form"NPDES Stormwater Permit Summary"contains a section"Owner
another contact Contact Person".This section lists Sharon Myers as the contact person.Sharon is
update:* retired,so please replace her information with my information:Janet Clarke, 1120
Estes Dr, CB 1650,Chapel Hill, NC 27599-1650,[phone],
[e-mail] you!

Submitter's Name* Please enter your FIRST and LAST name
Janet Clarke
Phone Number* Please enter your phone number
9198430475
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
Date 1/23/2024
Questions? Contact [e-mail].

Review
Verify Permit No.* Revise permit number below if incorrect.
NCS000201