NCG030674_Owner Affiliation Change_20210510

and Land Resources Fi
qgiij ij% Division of Energy, Mineral,
Land Quality Section / Stormwater Program
1
National Pollutant Discharge Elimination System (NP.l7ES
PERMIT OWNER AFFILIATION DESIGNATION FORM
(Individual Legally Responsible for Permit)
Use this form if there has been:
G CHANGE in facility ownership or facility name, but, the i
who is legally responsible for the permit: ha.s change
the name of the facility has changed, or if the ownership of the facility
do NOT use this form. Instead, you must fill out a Name -Ownership Ch
and submit the completed form with all required documentati
.:` es "legally responsible individual" mean?
om is either:
the responsible corporate officer (for a corporation);
the principle executive officer or ranking elected official (for a municipality, slate-r1-
-1gency);
lie general partner or proprietor (for a partnership or sole proprietorship);
r the duly authorized representative of one of the above.
Fler the permit number for which this change in Legally Responsible Individual'��`
es;
Individual Permit (or) Certificate d# (-'ov'ena,
( C S 0 3 0�6 7 4 ��GN��
;Pity Information:
i:1 eahty name: Hallman Foundry LLC _
rnpany/Owner Organization: Non-Governement
,iI ty address: 105 E Humber St
Addresk
Sanford NG
City Sta e
�e c1�ra-ent legally responsible person associated with your permit, go to this �ti=ebsi,+.
" ic.gov/about/d1visions/energy-mInerat-laiid-resources/eiiergylm,ixicral-lasl per €t
and:un the Permit Contact Summary Report.
OWNER AFFILIATION that should be removed:
,%,Ious legally responsible individual: Alan Heckle
l
First. MI
'WNER AFFILIATION (legally responsible for the permit):
. --son legally responsible for this permit: Jeremy EiR ite
First MI
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NPDES Stormwater Permit OWNER AFFILIATION DIESIGNA"rl 4 '
Form (if no Facility Name/Ownership Change)
Title x
Mailing Address
City State >�
Telephone L Inail _ _.
Fax Number
ason for this change:
i;
❑✓ Employee or management ch r,,g
�, ,result of:
Inappropriate or incorrect des I Q na € i .o.'c
❑ Other
`other please explain: --
.................................................................. ....a
�. certification below must be completed and signed by the perlqOt hoidel---
"IR!'ITIRIFFEE CERTIFICATION:
ay EIRite attest that this application for this change ttt Ooo ._;.;.°
='�n legally responsible for the permit) has been reviewed and is accurate and < ontpaeis ru !` bes "d, n�'
dge. I understand that if all required parts of this form are not completed, this 4's ;xrl � ��
.:-.....
— Signature late
PLEASE SEND THE COMPLETED FORM TO:
DEMLR - Storrnwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
For more information or staff contacts, please call [phone] or vast. thc'
at: http://deg.ne.,,ov/about/divisions/enel,�,,y-mineral-land-resoui-ces/stcrpn,A to
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