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HomeMy WebLinkAboutNCG120047_Owner Affiliation Change_20210602Division of Energy, Mineral, and Land Resources Land Quality Section / Stormwater Program w National Pollutant Discharge Elimination System (NPDES) Energy, t finercal & PERMIT OWNER AFFILIATION DESIGNATION FORM Land Resources ENVAONIONTAL C4VA „Y (Individual Legally Responsible for Permit) Use this form if there has been: FOR AGENCY USE ONLY Date Received Year Mondi 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 (far 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 j 1 12 10 16 4 7 2) Facility Information: Facility name: Haywood Co -White Oak Sanitary Company/Owner organization: Santek Environmental of North Carolina LLC Facility address: 3898 Fines Creek Road Address Waynesville NC 28785 City State Zip To find the current legally responsible person associated with your permit, go to this website: h s://de .ne. ov/about/divisions/ener -mineral-land-resources/ener -mineral-land- ermits/n des-industrial- rp ogram and run the Permit Contact Summary Report. 3) OLD OWNER .AFFILIATION that should be removed: Previous legally responsible individual: Ron Vail First MI Last 4) NEW OWNER AFFILIATION (legally responsible for the permit): Person legally responsible for this permit: Stephen Slater First MI Last Page I of 2 S WU-0WNERAFFMANov2019 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: General Manager Title 1070 Riverside Drive Mailing Address Asheville NC 28804 City State Zip (828 ) 251-4888 sslater@republicservices.com Telephone E-mail Address f 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: 1, Stephen Slater , attest that this application for this change in Owner Affiliation (person legally responsible for thepermit) has been reviewed and is accurate and complete to the best of my knowledge n e d that if all r uired parts of this form are not completed, this change may not be proce 2- zi Signature I 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.ne.gov/about/divisions/energy-mineral-land-resources/stormwater Page 2 of 2 S W U-DWNERAFFIL-4Nov2019