NCG120023_Owner Affiliation Change_20220413

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Division of Energy, Mineral, and Land Resources
��.��oiN;;R,e \, Land Quality Section / Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
PERMIT OWNER AFFILIATION DESIGNATION FORM
(Individual Legally Responsible for Permit)
Use this form if there has been:
POR AGENCY USE ONLY
Date Recciwd
Year
Montle
I Day
MUDGM&Z"ariall go
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 °9egally 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.
I) Enter the permit mrmber for which this change in Legally Responsible Individual ("Owner Affiliation")
applies:
Individual Permit (or)
N I C I S
2) Facility Information:
Certificate of Coverage or No Exposure
N C G` I D O a 3
Facility
Company/Owner Organization: � r LzdSIMU2
Facility address: 'il5 MPn!)eu1NPIJ QDe 1
Address
-r�9sov,w114, AIC 0285yo
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
https://deg.nc.Rovlswl Navigate to the "NPDES Industrial Program" section and run the Stormwater Permit
Contact Summary Report for your permit number.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Me IISSk ii �'lOorP_
First MI Lasl
A) NSW OWNER AFFILIATION (legally responsible for the pernnit):
Person legally responsible for this permit:
�Y��MrN � t/�JGYVtN
First MI Last
Last revised 20 reb 2022
Page 1 of

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
5) Reasmr far this change:
As: �64tAv.-)' CU�e Wl0oni er
Titled-- `�
asy uw C6rrcdo� R/Vd
Mailing Address
3o,LksenyjjL NC CWY&r
City State Zip
(910 ) 30( ,g(7/ 7 6on�mmrn_ (�grrsn�l.r tuan'iynCOOV
Telephone E-mail Address
Fnx Number
A result of: L1� Employee or management change
® Inappropriate or incorrect designation before
❑ Other
Ifotherplease explain:
...................................................................................................................
The certification below must be completed and signed by the permit holder.
Note: 40 CFR 122,22(c) requires an original signature (not digital)
PERMITTEE CERTIFICATION:
I' /�inrnr� S_ l�arvtr ,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.
I//l3koaa
77 Signature Date
PLEASE SEND THE ORIGINAL SIGNED COPY OF THE COMPLETED
OWNER AFFILIATION CHANGE 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 website
at: httpa/deq.nc.gov/sw
Per NC General Statute 143-215.613 (i), any person who knowingly makes any false statement, representation, or
certification in any applicatimt, record, report, plan, or other document filed or required to be maintained under this
Article or a rule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars ($10,000).
Page 2 of 2
Last revised 20 Feb 2022