NCS000592_Permit Contact Update Request_20240404

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by Anonymous User 4/4/2024 10:13:39 AM(Permit Contact Update Request)
Approve by Austin Sanderford 5/16/2024 9:26:40 AM(Contact Update Review)
0 Updated 5/16/2024 AAS
• The task was assigned to DEMLR SW Admin General.The due date is: May 16,2024 5:00 PM
4/4/2024 10:13:44 AM
• The task was assigned to Joyce Sanford by round robin distribution 4/4/2024 10:13:44 AM
• Joyce Sanford reassigned the task to Austin Sanderford 4/29/2024 10:56:11 AM

DEQIwo NPDES Stormwater -Request
Request Submitted
NPDES Permit Enter your NPDES stormwater permit number or Certificate of Coverage(COC)number.
Number* NCS000592
Begins with NCS,NCG,or NCGNE(no exposure)
Facility Name* Culpeper Of Roanoke Rapids
(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 Storm Water Owner Change04-04-2024-094802.pdf 450KB
pdf only
Permit Contact Update
Provide new permit contact information
This person should REPLACE the current permit contact.
This person should just be added as another permit contact.
New Contact Name* First and Last Name
Donna Fodor
E-mail Address* [e-mail]
Phone No.* 252-507-6070
Mailing Address* 2262 West 10th Street
Physical Address If different than mailing address

Add another permit contact if needed by clicking the'Add'button below
Submitter's Name* Please enter your FIRST and LAST name
Donna Fodor
Phone Number* Please enter your phone number
2525076070
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
cY/wwwet P- of
Date 4/4/2024
Questions? Contact [e-mail].

Review
Verify Permit No.* Revise permit number below if incorrect.
NCS000592