Loading...
HomeMy WebLinkAboutNCG080944_Owner Affiliation Change_20210218Division of Energy, Mineral, and Land Resources Land Quality Section / Stormwater Program w National Pollutant Discharge Elimination System (NPDES) Energy, Mineral& PERMIT OWNER AFFILIATION DESIGNATION FORM Land Resources -NVIRONMENTAL OIJALITY (Individual Legally Responsible for Permit) Use this form if there has been: FOR AGENCY USE ONLY Date Received Year Month Day 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 N I C I S 2) Facility Information: Facility name: Company/Owner Organization Facility address: (or) Certificate of Coverage or No Exposure N I C I G 10 18 10 19 4 4 Raleigh Yard CSX Transportation, Inc. 860 Semart Drive Address Raleigh NC 27604 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-re source s/energy-mineral-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: Meaghan Atkinson First MI Last 4) NEW OWNER AFFILIATION (legally responsible for the permit): Person legally responsible for this permit: Samuel Ross First MI Last S WU-O WNERAFF IL4Nov2019 Page 1 of 2 NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION Form (if no Facility Name/Ownership Change) Director Environmental Field Services Title 500 Water Street, J275 Mailing Address Jacksonville FL 32202 City State Zip ( 904 ) 359-3691 samuel_ross@csx.com Telephone E-mail Address ( ) Fax Number 5) Reason for this change: Employee or management change A result of: Inappropriate or incorrect designation before Other If other please explain: The certification below must be completed and signed by the permit holder. PERMITTEE CERTIFICATION: I Samuel floss , 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. 02/18/2021 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 (919) 707-9220 or visit the website at: http://deg.nc.gov/about/divisions/energy-mineral-land-resources/stormwater Page 2 of 2 S WU-OWNERAFFIL-4Nov2019 ht I February 4, 2021 Mr. Samuel Ross Director Environmental Field Services CSX Transportation, Inc. 500 Water Street, J-275 Jacksonville, FL 32202 Dear Mr. Ross, 500 Water Street Jacksonville, FL 32202 Phone: (904) 366-4245 E-Mail: Nathan _Goldman a,csx.com NATHAN D. GOLDMAN Executive Vice President & Chief Legal Officer You handle matters pertaining to compliance with Federal, State, and local environmental laws and regulations. One of your responsibilities is preparing permit applications, variance requests, report forms and certifications, and such other documents and papers as necessary to assure compliance with environmental laws and regulations. Accordingly, I hereby authorize you to sign the necessary environmental documents on behalf of the Company to carry out your work. effect. This authorization is in addition to electronic agency permitting submissions currently in Sincerely, yzo , 4' Nathan D. Goldman