NCG021044_Permit Contact Update Request_20250929

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by Anonymous User 9/29/2025 11:03:21 AM (Permit Contact Update Request)
Approve by bradley.bennett 12/2/2025 1:26:51 PM (Contact Update Review)
0 Please ensure that the signed hard copy of the DOSA Form has been submitted to our office.
The form indicated a zip code of 27713 for the Boylan Ave address in Raleigh, but this is a Durham
zip code? We used 27603 which seems to be the correct zip code. Please advise if this zip code is
incorrect.
• The task was assigned to DEMLR SW Admin General.The due date is: November 10,2025 5:00 PM
9/29/2025 11:03:27 AM
• The task was assigned to Austin Sanderford by round robin distribution 9/29/2025 11:03:27 AM
• bethany.georgoulias reassigned the task to Mike.Lawyer 10/27/2025 3:01:19 PM
•Reassigning Austin's tasks in LF forms
• bradley.bennett reassigned the task to bradley.bennett 12/2/2025 11:30:28 AM

DEQNPDES Stormwater
e
Request Submitted
NPDES Permit Enter your NPDES stormwater permit number or Certificate of Coverage(COC)number.
Number* NCG021044
Begins with NCS,NCG,or NCGNE(no exposure)
Facility Name* 401 Sand Mine
(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 Signed SW-DOSA-Form-20241004-DEMLR-SW ARBD
185.26KB
Mine.pdf
pdf only
Submitter's Name* Please enter your FIRST and LAST name
Xiong Vang
Phone Number* Please enter your phone number
9197471510
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
�eh�9
Date 9/29/2025
Questions? Contact [e-mail].

Review
Verify Permit No.* Revise permit number below if incorrect.
NCG021044