NCS000250_Owner Affiliation Change_20200224

Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
N. rv. National Pollutant Discharge Elimination System (NPDES)
Energy. Mineral & Land Resources PERMIT OWNER AFFILIATION DESIGNATION FORM
ENVIRONMENTAL QUALITY (Individual Legally Responsible for Permit)
Use this form if there has been:
FOR AGENCY USE ONLY
Date Received
Year
I Month
I Da
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 I C I S 10 10 1 N I C I G
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
North Carolina Department of
1501 Mail Service Center
Address
Raleigh NC 27699-1501
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
https://deg.nc.gov/about/divi sions/energy-mineral-land-resources/energy-m ineral-land-permits/npdes-industrial-
rp ogram and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: James H Trogdon
First M1 Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
J. Eric Boyette
First mi Last
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NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
5) Reason for this change:
A result of:
If other please explain: Note,
Secretary of North Carolina Department of Transportation
Title
1501 Mail Service Center
Mailing Address
Raleigh NC 27699-1501
City State Zip
( 919 ) 707-2800 [e-mail]
Telephone E-mail Address
(919 1 733-9150
Fax Number
0 Employee or management change
❑ Inappropriate or incorrect designation before
❑ Other
will be effective on 3/1/2020
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
1 James H. Trogdon attest that this application for this change in Owner Affiliation
(person legally responsible for the it) has been reviewed and is accurate and complete to the best of my
knowledge. I understand `hat if al req d parts of this form are not completed, this change may not be
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/energv-mineral-land-resources/stormwater
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