SW3141103_Application Form_20240416 (4)

DEMLR USE ONLY
Date Received Fee Paid Permit Number
STATE STORMWATER:
PERMIT INFORMATION UPDATE APPLICATION FORM
There is NO FEE for updating project name or permittee information.
This form is to only to be used by the current permittee to notify the Division of:
1) changes to the Point of Contact(signing official) for the current permittee (LLC, Corporation, HOA or POA);
2) changes to the mailing address, phone number or email address of the current permittee;
3) changes to the name of the project; and
4) changes to the legal corporate name as documented by a Name Change or Merger filed with the NCSOS.
A. NEW PERMIT INFORMATION
State Stormwater Permit Number: SW3141103
Are you updating If so, please provide the updated information:
(check all that apply):
® Project name Agility— Building Expansion
❑ Corporation Name'
❑ Permit Contact Name2,3
❑ Permit Contact Title
❑ Mailing Address3
❑ Phone number
❑ Email address
' Provide documentation such as a Name Change/Merger filed with the NCSOS.
2 Provide supporting documentation such as NCSOS filing. The permit contact's position must be in accordance
with 15A NCAC 02H .1040(1).
3 If more than one point of contact or mailing address is being changed, please attach a separate sheet.
B. CERTIFICATION OF PERMITTEE
I, Brad Garner , the current permittee, hereby notify DEMLR that I am making the changes as listed in Section A above.
I further attest that this application for an update to the permit information currently on file is accurate and complete to the
best of my knowledge.
Signature: �. Date: ���� /, Z�Z-y
rr�h , a Notary Public for the State of
County of /1Wall , do hereby certify that boa' (3apii ,i
ppierisaRrwared before me this the / day of naeli , 20 4, and acknowledge the due
•orgoing instrument. Witness my hand and official seal,
gssIon •. /y
•
PUBLIC
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My ni1MMtfesion expires
Stormwater Permit Information Update Form Page 1 of 1 May 11, 2017