NCG020895_Owner Affiliation Change_20210603

Division of Energy, Mineral, and band Resources
Land Quality Section / Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
Energy, Mineral & PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resources ENVIRONMENTAL QUALITY (Individual Legally Responsible for Permit)
FOR AGENCY
USE ONLY
bw Received
Year
Month
llay
Use this form if there has been:
NO CHANGE in facility ownership or facility name, but the in ividwgl
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 rill 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 (or) Certificate of Coverage or No Exposure
N I C I S N C I G 10 12 0 18 19 15
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
Aurelian Springs Mine
Iluka Resources NC LLC C/O Iluka Resources Inc
12472 St. John Church Road
Address
Stony Creek Virginia 2 882
City State zip
To find the current legally responsible person associated with your permit, go to this website:
rp ogram and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual:
Clifford W Gillham
First MI
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: Stuart
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NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
Vice President
Title
12472 St. John Church Road
Mailing Address
Stony Creek Va 23882
City State Zip
(804 )586-9224 [e-mail]
Telephone E-mail Addre s
o/SS—
Fax Number
5) Reason for this change:
A result of: ❑ Employee or management change
❑ Inappropriate or incorrect designation
❑ Other
If other please explain:
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
1 �'���T G e j 4e.7/J � c / —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. 1 understand that if all required parts of this form are not completed, this change ay not be
processed.
Signature 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 [phone] or visit the we
at: httD://deo.nc.eov/about/divisions/enerRv-mineral-land-resources/stormv
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