NCG060100_Owner Affiliation Change_20210802

Energy. Mineral &
L and Resources
FNvIA/]NMENTAl QUALITY
Division of Energy. Mineral, and Land Resources
Land Quality Section / Stormwater Program
National Pollutant Discllaroe Elimination System (N-PDES)
PERMIT OWNER AFFILIATION DESIGNATION FORM
(Individual Legally Responsible for Permit)
Use this form if there has been:
FOR AGENCY l: SE ONLY
Dave Received
Yew
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 niunicipality. 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 ror which this change in Legally Responsible Indh1duaI ("Owner A'illiadon")
applies:
individual Permit
N C I S
2) Facility- Information:
Facility name:
Company O[vner Organization:
Facility address:
fors Certificate of Coverage or No Exposure
N I C I G 10 16 10 11 0 0
Coastal Protein
Kansas City Sausage Company LLC
1600 Martin Rd
Address
Godwin NC 28344
City state Zap
To find the current legally responsible person associated with your permit. go to this svebsite:
https://d eg.nc.gov/abouVdivisions/energy-mineral-land-resources/energy-mineral-land-perniits/npd es-industrial-
rp ogram and run the Permit Contact Summary Report.
3) OLD ONVVER AFFILIATION that should be removed:
Previous legally responsible 1ndividuaL Brady Stewart
Faa t MI Last
4) = OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this pernut: Steven Corbett
Fu t N I I Last
Paz 1 of-'
5 19

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
Plant Manager
Title
1600 Martin Rd
INtailing Address
Godwin NC 28344
City State Zip
(910 ) 5676104 scorbett(Dsmithfield.com
Telephone E-nkail Address
(910 ) 5675241
Fa.-, Nwmei
S) Reason for this change:
A result of:
Q Employee or management change
0 Inappropriate or incorrect designation before
❑ Other
If other please explain:
The certification below must be completed and signed by the permit holder.
IJ4 I'M I101:4X41131141ISCo.'%ICiNS
I. Steven Corbett . attest that this application for this change in Owner Affiliation
(person legally responsible for the perrtut) has been reviewed and is accurate and complete to the best of nnr
knowledge. I understand that if all required parts of this form are not completed. this change near not be
processed.
�. w--...._.�..___......- 8/2/202 !
Signature Date
PLEASE SEND THE COMPLETED FORA TO:
DEN LR - Storinwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh. Noith Carolina 27699-1612
For more information or staff contacts. please call [phone] or visit the website
at: http://deg.nc.gov/about/divisions/energy-mineral-land-resources/storinwater
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