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HomeMy WebLinkAboutNCS000494_Owner Affiliation Change_20230804 ' D_Ecl?,,,,) Division of Energy,Mineral, and Land Resources FOR AGENCY USE ONLY NORTH Land QualitySection/Stormwater Program Date Received owxmbntmentronmem.io�.,o� /`� g Year Month Day �/ National Pollutant Discharge Elimination System (NPDES) PERMIT OWNER AFFILIATION DESIGNATION FORM (Individual Legally Responsible for Permit) Use this form if there has been: 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 (or) Certificate of Coverage or No Exposure N C S 0 0 0 4 94 N C G 2) Facility Information: Facility name: Town of Lewsiville Company/Owner Organization: Town of Lewisville Facility address: 6550 Shallowford Road Address Lewisville NC 27023 City State Zip To find the current legally responsible person associated with your permit,go to this website: https://deq.nc.govlsw/ 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: Chester Patterson First MI Last 4) NEW OWNER AFFILIATION(legally responsible for the permit): Person legally responsible for this permit: James Ayers First MI Last Page 1 of 2 Last revised 20 Feb 2022 NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION Form (if no Facility Name/Ownership Change) Town Manager Title PO Box 547 Mailing Address Lewisville NC 27023 City State Zip (336 )945-5558 jayers@lewisvillenc.net Telephone E-mail Address ( ) Fax Number 5) Reason for this change: A result of: MI Employee or management change ❑ Inappropriate or incorrect designation before ❑ Other If other please 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, James Ayers , 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. 4)� August 4, 2023 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(919) 707-9220 or visit the website at: http://deq.nc.gov/sw Per NC General Statute 143-215.6B(i), any person who knowingly makes any false statement, representation,or certification in any application,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