NCG110151_Permit Contact Update Request_20241008

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by Anonymous User 10/8/2024 10:25:37 AM (Permit Contact Update Request)
Approve by Austin Sanderford 12/17/2024 3:07:12 PM (Contact Update Review)
•Updated AAS 12/17/2024
• The task was assigned to DEMLR SW Admin General.The due date is: November 19,2024 5:00 PM
10/8/2024 10:25:43 AM
• The task was assigned to Austin Sanderford by round robin distribution 10/8/2024 10:25:43 AM

DEQIwo NPDES Stormwater -Request
Request Submitted
NPDES Permit Enter your NPDES stormwater permit number or Certificate of Coverage(COC)number.
Number* NCG110151
Begins with NCS,NCG,or NCGNE(no exposure)
Facility Name* West Brunswick Regional WRF
(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
Matthew Henry
E-mail Address* [e-mail]
Phone No.* 910-253-2479
Mailing Address* P.O. Box 249, Bolivia, NC 28422
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 Persons:
another contact Please add Donald Dixon to the Owner Contact Person list.
update:*
Title: Deputy Director of Wastewater Operations
Address: P.O. Box 249, Bolivia, NC 28422
Phone:[phone]
Email:[e-mail]

Submitter's Name* Please enter your FIRST and LAST name
Krysden Burden
Phone Number* Please enter your phone number
910-253-1757
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
41_1<1214
,�Gro�6N
Date 10/8/2024
Questions? Contact [e-mail].

Review
Verify Permit No.* Revise permit number below if incorrect.
NCG110151