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HomeMy WebLinkAboutNCS000105_Owner Affiliation update_20210428Division of Energy, Mineral, and Land Resources Land Quality Section / Stormwater Program A National Pollutant Discharge Elimination System (NPDES) Energy, Mineral & PERMIT OWNER AFFILIATION DESIGNATION FORM Land Resources ENVIRONMENTAL QUALITY (Individual Legally Responsible for Permit) Use this form if there has been: FOR AGENCY USE ONLY Date Received Year Month Day REC IN/F0 APR 28 l0- 1 DENR-L AND 0UALI T ,,( STORI 7MATER PEMo-r"1'i NO CHANGE in facility ownership or facility name, but the individual who is legally responsible for the permit has changed. If the name of the facility has changed, or if the ownership of the facility has changed, do NOT use this form. Instead, you must fill out a Name -Ownership Change Form and submit the completed form with all required documentation. What does "legally responsible individual" mean? The person is either: • the responsible corporate officer (for a corporation); • the principle executive officer or ranking elected official (for a municipality, state, federal or other public agency); • the general partner or proprietor (for a partnership or sole proprietorship); • or, the duly authorized representative of one of the above. 1) Enter the permit number for which this change in Legally Responsible Individual ("Owner Affiliation") applies: Individual Permit N I C I S 10 10 10 11 0 15 2) Facility Information: Facility name: Company/Owner Organization: Facility address: (or) Certificate of Coverage or No Exposure N I C I G Canton Mill Blue Ridge Paper Products LLC (dba Evergreen Packaging) 175 Main Street Address Canton NC 28716 City State zip To find the current legally responsible person associated with your permit, go to this website: https://deg. nc. gov/about/divisions/energy-mineral-land-resources/energy-mineral-land-permits/npdes-industrial- rp ogram and run the Permit Contact Summary Report. 3) OLD OWNER AFFILIATION that should be removed: Previous legally responsible individual: Wallace First 4) NEW OWNER AFFILIATION (legally responsible for the permit): Person legally responsible for this permit: McDonald MI Last Fred J Perrett First MI Last S WU-0WNERAFFIL4Nov2019 Page 1 of 2 NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION Form (if no Facility Name/Ownership Change) Vice President Operations, Acting General Manager - Canton Mill Title 175 Maln Street Mailing Address Canton NC 28716 City State Zip (901 ) 275-4531 fred.perrett@everpack.com Telephone E-mail Address ( ) Fax Number 5) Reason for this change: ❑✓ Employee or management change A result of ❑ Inappropriate or incorrect designation before ❑ Other If other please explain: The certification below must be completed and signed by the permit holder. PERMITTEE CERTIFICATION: I Fred J. Perrett , attest that this application for this change in Owner Affiliation (person legally responsible for the permit) has been reviewed and is accurate and complete to the best of my knowledge. I understand that if all required parts of this form are not completed, this change may not be processed. Signature Z1 �P2z Date PLEASE SEND THE COMPLETED FORM TO: DEMLR - Stormwater Program Dept. of Environmental Quality 1612 Mail Service Center Raleigh, North Carolina 27699-1612 For more information or staff contacts, please call (919) 707-9220 or visit the website at: http://deg.nc.gov/about/divisions/energy-mineral-land-resources/stonnwater Page 2 of 2 S WU-O WNERAFFIL-4Nov2019