NCS000166_Owner Affiliation Change_20210329

Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
Enetay. Mineiid8 PERMIT OWNER AFFILIATION DESIGNATION FORM
Lrrnd Ne urrce-S
IN, W,NHFNI�I fw:di71 (Individual Legally Responsible for Permit)
Use this form if there has been:
FOR AGENCY USE ONLY
Data 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, fcdcral 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
2) Facility Information:
Facility naive:
Company/Owner Organization
Facility address:
(or) Certificate of Coverage or No Exposure
N I C I G
Lewiston
Perdue Foods LLC
3539 Governors Rd
Address
Lewiston NC 27849
City State Zip
To find the cun-ent legally responsible person associated with your permit, go to this website:
Irtt s:/Idr .nc. ov/about/divisions/ener -mineral-land-resources/encr -mineral-land- erinits/n des-industrial-
rp ogram and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual:
Frank
Koekkoek
First Mf Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: G. Andrew Gutty
First MI List
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SWU-OWNERAFFILdNov2019

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no FacHity Name/Ownership Change)
Assistant General Counsel
Title
PO Box 1537
Mailing Address
Salisbury MD 21802
City State zip
(410 ) 341-2191 [e-mail]
Telephone E-mail Address
Fax Number
5) Reason for this change:
A result of: ❑ Employee or management change
inappropriate or incorrect designation before
Other
if other please explain: Change to the person overseeing all NC stormwater facilities
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTWICATION:
1 G. Andrew Getty , attest that this application for this change in Owner Affiliation
(person legally responsible for the pen -nit) 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 Date
PLEASE SEND THE COMPLL+'TED FORM TO:
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Set vice Center
Raleigh, North Carolina 27699-1612
For more information or staff contacts, please call [phone] or visit the website
at: http://deg.nc.gov/aboutidivisions/ctiergy-minemi land-resources/stormwater
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