NCGNE1051_Owner Affiliation Change_20210202

N'r.`0
Energy, Mineral &
Land Resources
ENVIi,JNMENTAL ,;UAL TY
Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
FOR AGENCY USE ONLY
Date Received
Year
Month
Day
PERMIT OWNER AFFILIATION DESIGNATION FORM
(Individual Legally Responsible for Permit)
Use this form if there has been: 2021
c I I l t
NO CHANGE in facility ownership or facility name, but the indlvAduaf ;, ; it�(�
who is legally responsible for the permit has chatg'
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 I I I I I I I N I C I G IN I E 11 10 5 11
2) Facility Information:
Facility name: Circle Graphics
Company/Owner Organization: Circle Graphics Inc.
Facility address: 101700 World Trade Blvd., Suite 102
Address
Raleigh NC 27617
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
https //deg nc gov/about/divisions/energy-mineral-land-resources/energy-mineral-land-permits/npdes-industrial-
ro ram and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual:
Mike Keyes
First MI
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
Brian
First MI
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Last
Studt
Last
S WU-O WNERAFFIL4Nov2019

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:
Director of Operations
Title
10700 World Trade Blvd.
Mailing Address
Raleigh NC 27617
City State Zip
( 919 ) 864-4546 [e-mail]
Telephone E-mail Address
Fax Number
Employee or management change
® Inappropriate or incorrect designation before
® Other
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
I Brian Studt , 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 undW45F7
ompleted, this change may not be
processed. /Y/�
gauDate
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-O WNERAFFIL-4Nov2019