NCC211423_Contact Update Request (Legally Resp Change)_20230320

Use this form when:
The person who is legally responsible for the permit has changed, but there is NO CHANGE in the project name
or ownership.
**If the project name has changed, or if the ownership of the project has changed, do NOT use this form.**
Instead, you must submit a new NCG01 electronic Notice of Intent (eNOI).
Directions:
Print this form, complete, scan and upload to the Construction Stormwater Permit MODIFICATION Form.
Then, mail the original form to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6th Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM UNTIL YOUR MODIFICATION HAS BEEN REVIEWED AND ACCEPTED AS COMPLETE.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.22]
Certificate of Coverage (COC) Number: NCC 211423
Name of Project: Atrium Health Union West Offsite Roa
Legally Responsible Organizational Entity: Charlotte Mecklenburg Hospital Authority
PREVIOUS Legally Responsible Individual: Thomas (Tom) WA hington
NEW Legally Responsible Individual: Amanda Mewborn
The following section is to be completed and signed by the NEW Legally Responsible Individual.
Per NC General Statute 143-215.6E (i), any person who knowingly makes any false statement, representation,
or certification in any application, record, report, plan, or other document filed or required to be maintained
under this Article or a rule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may
include a fine not to exceed ten thousand dollars ($10,000).
Page 1 of 2

NCG
fLegally ResponsibleChange Forrl
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.211
Under penalty of law, I certify that (check all boxes to indicate your agreement):
[X I am the person responsible for the construction activities of this project, for satisfying the
requirements of this permit, and for any civil or criminal penalties incurred due to violations of this
permit.
�i I will abide by all conditions of the NCGO10000 General Permit and the approved Erosion and
Sediment Control Plan.
If the approved Erosion and Sediment Control Plan is not compliant with Part II (Stormwater Pollution
Prevention Plan) of the NCG010000 General Permit, I will nonetheless ensure that all conditions of
Part II of the permit are met on the project at all times.
® I understand that coverage under this permit will constitute the permit requirements for the
discharge(s) and is enforceable in the same manner as an individual permit.
X1 This form has been reviewed and is accurate and complete to the best of my knowledge.
gnature: Date: --3) to ht')
Print Name of Signed: Amanda Mewborn
Title: Vice President
Mailing Address:'
Street Address:
Email Address: amanda mewborn@atriumhealth org
Phone Number: — `
* IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the
construction activity, such as a president, secretary, treasurer, or vice president, or a manager that is
authorized in accordance with Part IV, Section B, Item (6) of the NCG010000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCG010000 permit.
Page 2 of 2

Georgoulias, Bethany
From: Mewborn, Amanda G <[e-mail]>
Sent: Monday, March 20, 2023 10:35 AM
To: Georgoulias, Bethany; Tidd, Nathan
Subject: [External] RE: Construction SW General Permit NCC211423 - PLEASE UPDATE RESP
PERSON
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
Hello Bethany,
I approve this change, and mailed the original paper copy last week.
Thank you!
Amanda
Amanda Mewborn
Vice President, Planning, Design, and Construction
Facilities Management Group
Mobile: [phone]
Atrium Health
From: Georgoulias, Bethany <[e-mail]>
Sent: Monday, March 20, 2023 10:06 AM
To: Tidd, Nathan <[e-mail]>; Mewborn, Amanda G <[e-mail]>
Subject: [EXTERNAL] RE: Construction SW General Permit NCC211423 - PLEASE UPDATE RESP PERSON
WARNING: This email originated from outside of Atrium Health( ,[e-mail]). DO NOT click links
or open attachments unless you know and trust the sender. NEVER provide your password to anyone, and use the
squish the Phish button to report any suspicious email. ANIL J1111111111
Email to me is fine (no need to upload it with a Modification form); however, I need a confirmation from the permittee
contact (Ms. Mewborn) for this change. A reply to this email is fine.
The original signed paper copy should be mailed in.
Thank you,
Bethany Georgoulias (she/her)
Environmental Engineer, Stormwater Program
DEMLR Laserfiche Administrator
Division of Energy, Mineral, and Land Resources
N.C. Department of Environmental Quality
919 707 3641 office
[e-mail]
512 N. Salisbury Street, Raleigh, NC 27604 (location)
1612 Mail Service Center, Raleigh, NC 27699-1612 (mailing)

Website: httl2://deq.nc.gov/about/divisions/energy-mineral-land-resources/stormwater
D_E
NORTH CAROLINA
Department of Environmental quality
Email correspondence to and from this address is subject to the North
Carolina Public Records Law and may be disclosed to third parties.
From: Tidd, Nathan <[e-mail]>
Sent: Monday, March 20, 2023 9:23 AM
To: Georgoulias, Bethany<[e-mail]>
Subject: [External] Construction SW General Permit Annual Fee - NCC211423 - PLEASE UPDATE RESP PERSON
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
Good Morning Bethany,
We received the executed change form attached. Please let me know if there's a way for us to upload it or if you can
handle entering it into the system from your side.
Regards,
Nathan Tidd, PLA
Kimley-Horn 1200 S Tryon St., Charlotte, NC 28202
Direct: 704-319-5686 1 Mobile: [phone]
Connect with us: Twitter I Linkedln I Facebook I Instac ra am I Kimley-Horn.com
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