NCG130040_Permit Contact Update Request_20240312

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by Anonymous User 3/12/2024 9:56:29 AM (Permit Contact Update Request)
Approve by Austin Sanderford 4/23/2024 12:34:00 PM (Contact Update Review)
0 Updated 4/23/24 AAS
• The task was assigned to DEMLR SW Admin General.The due date is:April 23,2024 5:00 PM
3/12/2024 9:56:34 AM
• The task was assigned to Joyce Sanford by round robin distribution 3/12/2024 9:56:34 AM
• Joyce Sanford reassigned the task to Austin Sanderford 4/16/2024 11:11:52 AM

DEQIwo NPDES Stormwater -Request
Request Submitted
NPDES Permit Enter your NPDES stormwater permit number or Certificate of Coverage(COC)number.
Number* NCG130040
Begins with NCS,NCG,or NCGNE(no exposure)
Facility Name* U S Tire Recycling LP
(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 NPDES-Owner-Affiliation-Change-Demlr-SW 01-
127.47KB
2024(2).pdf
pdf only
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
William'BY Kirby
E-mail Address* [e-mail]
Phone No.* 704-784-1210

Mailing Address* 6322 Poplar Tent Road,Concord, NC 28027
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 UST eDMR DOSA Signed.pdf 419.8KB
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
William'BY Kirby
E-mail Address* [e-mail]
Phone No.* 704-784-1210
Mailing Address* 6322 Poplar Tent Road,Concord, NC 28027
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 Owner Contact Person should be replaced with:William'BX Kirby,
another contact [e-mail],704-784-1210,6322 Poplar Tent Road,Concord, NC
update:* 28027
Submitter's Name* Please enter your FIRST and LAST name
Caroline L. Funderburk
Phone Number* Please enter your phone number
919-738-9583
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
<liar/�t�ii I F
Date 3/12/2024
Questions? Contact [e-mail].

Review
Verify Permit No.* Revise permit number below if incorrect.
NCG 130040