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HomeMy WebLinkAboutNCS000566_Permit Contact Update Request_20230310Action History (UTC-05:00) Eastern Time (US & Canada) Submit by Anonymous User 3/10/2023 5:53:14 AM (Permit Contact Update Request) Approve by Kieu Tran 4/4/2023 9:39:29 AM (Contact Update Review) • The task was assigned to DEMLR SW Admin General. The due date is: April 21, 2023 5:00 PM 3/10/2023 5:53:18 AM • The task was assigned to Kieu Tran by round robin distribution 3/10/2023 5:53:18 AM Request Submitted NPDES Permit Enter your NPDES stormwater permit number or Certificate of Coverage (COC) number. Number* NCS000566 Begins with NCS, NCG, or NCGNE (no exposure) Facility Name* Fortress Wood Products (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 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 Dave Maddox E-mail Address* dmaddox@comcast.net Phone No.* 2768060178 Mailing Address* P. O. Box 4244 Martinsville, Virginia 24115 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 Dave Maddox Phone Number* Please enter your phone number 2768060178 Any format is fine. Email Address* Please enter a valid e-mail address dmaddox@comcast.net 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 oddc�z> ewl?"m- Date 3/10/2023 Questions? Contact bethany.georgoulias@ncdenr.gov. Review Verify Permit No.* Revise permit number below if incorrect. NCS000566