NCG060321_Owner Affiliation update_20210310

Energy %hnerat 3
Land Re,,ourres
Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
PERMIT OWNER AFFILIATION DESIGNATION FORM
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FOR AGENCV USE ONLY
Date Received
Year
Month
Day
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Use this form if there has been: l?=NR-LAID QUALM
'i'ORP0u�!ATE PERMITT
NO CHANGE in facility ownership or facility name, but the indi% dualR
who is legally responsible for the permit has changed.
/f 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 aft required documentation.
What dates "ieg;Wy 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
any);
• the general partner or proprietor (for a partnership or sole proprietorship).
• or, the duly authorized representative of one of the above.
1) Foter the permit number for which this change in Legally Responsible individual ("Owner Affiliation")
applies:
Individual Permit
N C S
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
(or) Certificate of Coverage or No Exposure
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Address
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City State Zip
To find the current legally responsible person associated with your permit, go to this website:
https: dey_nc rgox about di%tstons energN-mineral-land-resources energy; -mineral -land -permits npdes-industrial-
pruggram and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual ivlS� l�
First M1 Last
4) NEW OWNER AFFILIATION (legally responsible f/or the permit): 1 I
Person legally responsible for this pernnit: -1 at,� \
First Mi Last
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S WU-OW'IERAFF1L4Nov2019

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form Of no Facility dame/Ownership Change)
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City State Zip
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Telephone E-n ail Add ess
Fax Number
5) Reason for this change. -
A result of.,Employee or management change
lnapproWiate or incorrect designation before
Q Other
#'other please explain:
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
1. ?A(A` a;Ak attest that this: application for this change in Owner Affiliation
(person legally responsii>• e for tfa 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
processe
Signature Date
PLEASE SEND THE COMPLETED FORM TO:
DENILR - 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 website
at: http: ' deq.nc.gov about, divisions ener;;y-mineral-land-resources,'stonn%%,ater
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S WU-OWNERAFFIL-4Nov2019