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HomeMy WebLinkAboutNCG140451_Permit Contact Update Request_20220321Action History (UTC-05:00) Eastern Time (US & Canada) Submit by Anonymous User 3/21/2022 2:40:52 PM (Permit Contact Update Request) Approve by Tran, Kieu M 3/22/2022 2:28:25 PM (Contact Update Review) • Georgoulias, Bethany A reassigned the task to Tran, Kieu M 3/22/2022 11:16 AM * DOSA designations The task was assigned to Georgoulias, Bethany A. The due date is: May 2, 2022 5:00 PM 3/21/2022 2:41 PM Request Submitted NPDES Permit Enter your NPDES stormwater permit number or Certificate of Coverage (COC) number. Number* NCG140451 Begins with NCS, NCG, or NCGNE (no exposure) Facility Name* Eagle Rock Concrete - Franklinton (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 Person(s) with Delegation of Signature Authority (DOSA) Delegation of Please upload the signed "Stormwater Permit Delegation of Signature Authority Form" Signature Authority NCG140451 DOSA-03212022135846-0001.pdf 651.25KB pdf only Submitter's Name* Please enter your FIRST and LAST name Dexter F Tart Phone Number* Please enter your phone number 919-781-3744 Any format is fine. Email Address* Please enter a valid e-mail address dexter@eaglerockconcrete.com 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 Date 3/21 /2022 Questions? Contact bethany.georgoulias@ncdenr.gov. Review Verify Permit No.* Revise permit number below if incorrect. N CG 140451