NCG130057_Owner Affiliation Change_20210628

Energy, Ml`)Ieral &
LandResout-ces
ENVIRONMENTAL QlJr1,�1'CY
Division of Energy, Mineral, and Land Resources
Land Quality Section / St t Program
National Pollutant Discharge Elimination System (NPDES)
PERMIT OWNER AFFILIATION DESIGNATION FORM
(Individual Legally Responsible for Permit)
Use this form if there has been:
FOR AGENCY USE ONLY
Date Received
Year Month Day
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ff the name of the facility has changed, or if the ownersNo"hip of the facility has cha�vged,
do NOT use this form. Instead, you must fill out aName-Ownership Change Form
and submit the completed form with all required documentation.
What does "1 Bally responsible individual" mean?
The person is ither,
0 the responsible corporate officer (for a corporation);
IP
• the principle executive officer or ranking elected official (far a municipality, sate, federal or other
agency);
• the general partner or proprietor (for a partnership or sole proprietorship);
• or, the duly authorized representative of one of the above.
1)
public
Enter the permit number for which this change in Legally Responsible Individual (60Wlle�° Affuflla$llon99�
apples: �
N I! C
Individual Permit
S1 I
2} Facility Information:
I
Facility name:
Company/Owner Organization:
Facility address:
(or� Certificate of Coverage or No Exposure
Capitol Waste C&D Transfer Station
capitol Waste Transfer, LLC
424 Warehouse Dr.
Address
Raleigh NC 27609
City State Zip
To end the current legally responsible person associated with your permit, go to this website:
ht s://de .nc. ov/�boui/divisions/energy-mineral-land-resources/ener�v-mineral-lanci..ner,,,;tq/n
pTogam and the P
ermit Contact Summary Report.
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3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual:
V
des -industrial -
Walter Hall, Jr.
First MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person Iegally responsible for this permit:
S WU-OWNERAFFIL4Nov2Q19
Josh Daher
First MI Last
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NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
Area President
Title
103 Rupert Road
Mailing Address
Raleigh NC 27603
City State Zip
919 876-8485 [e-mail]
Telephone
Fax Number
5) Reason for this change:
E-mail Address
❑✓ 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:
Josh Daher ,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 thi's form are not completed, this change may not be
processed.
4' 1
Signature
Date
PLEASE SEND THE COMPLETED FORM TO:
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mani Service Center
Raleigh, North Carolina 27699-1612
For more information or staff contacts, please call [phone] or visit the website
at: httU://deq.nc.Gov/about/divisions/energv-mineral-land--resources/stormwater
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