NCG020330_COMPLETE FILE - HISTORICAL_20140623

P710
STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
IV C& 0:;l O 3 36
DOC TYPE
'HISTORICAL FILE
❑ MONITORING REPORTS
DOC DATE
❑ � o/ q bG
YYYYMMDD

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NC®ENR
Nonni Crn DJ Mery or
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Division of Energy, Mineral and Land Resources
Land Quality Section / Stormwater Permitting Program
FOR AGENCY USE ONLY
Date Received
Year Month
I Day
National Pollutant Discharge Elimination System (NPDES) RECEIVED
PERMIT OWNER AFFILIATION DESIGNATION FORM ,UN 23 2014
(Individual Legally Responsible for Permit)
DENR-LAND QUALITY
if NO CHANGE in company or facility ownership or name has occurred.
If a Name Change and/or Ownership Transfer at the facility has prompted this change, do
NOT use this form. You must fill out the Name -Ownership Change Form and provide all
necessary supporting documentation instead.
1) Enter 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:
(ur) Certificate of Coverage
N I C I G O Z O 3 3 O
4191 Hwy 87 5
Address
moacuite KC 2155g
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
http:l/portal.ncdenr.org/web/Ir/sw-permit-contacts and run the Permit Contact Summary Report,
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual:
First MI Last
4) NEW OWNER AFFILIATION (Legally responsible for the permit):
Person legally responsible for this permit:
RANPY H - 5TI LL.5
First Ml Last
PLA91 h&FINF1GER
Tille
_4191 RWY, BY 5
Mailing Address
wmtulm SIC 27559
City State Zip
(9{9) (A.Z -401 [ „ _rh m.nLrn�M
Telephone E-mail Address
Far Number
SW U-OWNERAFFI L-22May2014
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NPDESStormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
5) Reason for this change:
A result of: [jr Employee or management change
❑ Inappropriate or incorrect designation before
❑ Other
If other please explain:
What does "legally responsible person" mean?
That 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 that person above.
The certification below must be completed and signed by the permit
holder.
PERMITTEE CERTIFICATION:
I, RAwny 4% STfl.ES , 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.
Signature
/ 7 - /y
Date
PLEASE SEND THE COMPLETED FORM TO:
Division of Energy, Mineral and Land Resources
Stormwater Permitting Program
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
For more information or staff contacts, please visit our website:
http://portal.nedenr.or r web/ir/stormwater
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SM-OWNERAFF IL-22May2014