NCG130027_Owner Affiliation Change_20171026

Division of Energy, Mineral, and Land Resources FOR AGENCY USE ONLY
Date Received
Land Quality Section / Stormwater Program Year Month Day
K, Iry National Pollutant Discharge Elimination System (NPDES)
Energy, Miners! & PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resources
ENVIRONMENTAL QUALITY (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
N C S N C G 1 3 0 1 0 2 7
2) Facility Information:
Facility name: Safety-Kleen Systems, Inc.
Company/Owner Organization: Safety-Kleen Systems, Inc.
Facility address: 6182 Old Mendenhall Road
Address
Archdale NC 27263
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
http://deq.nc. gov/about/divisions/energy-mineral-land-resources/energy-mineral-land-permits/stormwater-program
and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Phil Curry
First MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: John L. Fell
First MI Last
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S WU-OWNERAFFIL-23March2017

NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
Branch Manager
Title
6182 Old Mendenhall Road
Mailing Address
Archdale NC 27263
City State Zip
336 289-8257 [e-mail]
Telephone E-mail Address
( 336 ) 861-4250
Fax Number
5) Reason for this change:
A result of- Employee or management change
® Inappropriate or incorrect designation before
Ej Other
If other please explain:
The certification below must be completed and signed by the permit holder.
19117UI101Dl Wall 1171 11y[OF.%01130
1, Todd M. Blake , 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. Digitallysigned by Todd M. Blake
Todd M. DN: cn=Todd M. Blake, o=Safety-
Kleen Systems, Inc., ou,
Blake kleenl oordd.blUSe@safeTy-
Date: 2018.10.2608:44: 29-04'00' 10/26/2018
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 website
at: http://deg.nc.gov/about/divisions/energy-mineral-land-resources/stormwater
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S WU-OWNERAFFILr23 Mar2017