NCG060089_Contact Changes_20190314

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 (LLG, Corporation, NOA 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
PrrP1\/Pr)
State Stormwater Permit Number: NCG060089
MAR 14 7AIQ
Are you updating
(check all that apply):
LJ Project name
If so, please provide the updated information: DFNR-LAND QUALITY
STCRMWATER PERMITTING
❑ Corporation Name'
Permit Contact Name2 ,3
Caleb Mancuso
❑ Permit Contact Title
❑ Mailing AddresS3
Plant Manager
❑ Phune number
Email address
Caleb.mancuso(cDmoodydunbar.com
Provide documentation such as a Name Change / Merger filed with the NCSOS.
Provide supporting documentation such as NCSOS filing. The permit contact's position must be in accordance
with 15A NCAC 02H ..10400).
If more than one point of contact or mailing address is being changed, please attach a separate sheet.
B. CERTIFICATION OF PERMITTEE
I, 0a if b , 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 t of my knowledge
Signature: ,.�''r/C- '""__• Date:
I, \ A \00r ctV V�) 00�\ t 5 a Notary Public for the State of Kt)r C0.r-0 (i ►'
County of \-,t" v\-� do hereby certify that Co,Ve6 KL+n C L, S p
personally appeared before me this the I q day of f--V- b 20 i 01, and acknowledge the due
execution of the forgoing instrument. Witness my hand and official seal,
��.
(Notary Seal)
_ fir
Notary Signature
My commission expires
Stormwater Permit Information Update Form Page 1 of 1 f` ,'.. May 11, 2017