NCG030574_Owner Affiliation Change_20210729

Division of Energy, Mineral, and Land Resources
a .c.
Land Quality Section 1 Stvrmwater Program
National: Pollutant Discharge Elimination System (NPDES)
Energy,,Mineral.& PERMIT OWNER AFFILIATION DESIGNATION FORM
L andkesoarces
cmVIPbliMrNTAL.auniiry (Individual Legally. Responsible for Permit).
FOR AGENCY USE ONLY
Cate Received
Yew
Month
Asy
Use this form if there ..has been:
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 farm. instead; you must till 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 executiveofficer or t'ankirig elected official (for a .municipality, state, federal or other public
agency);.
• the general partner or. proprietor (for a partnership. or sole. proprietorship);
.0 or, the dulyauthorized representative ofone.of.the above.
1) Enter the permit number for which this: change in Legally.Responsible.Individeral (".owner Affiliation'.')
applies;.
Individual Permit {0r Certificate of Coverage or No Exposure
0 3 fl 15
2) Facility Information:
Facility name:
CornpanylOwner .Organization
Facility address:
Doosan Portable Power A div of Clark Equipment
Clark Equipment Co.mpny
1293 GIL-enway :Dr.
.Address
StatesVille NC 28625
City State. Zip.
To find the current legally responsible person associated with your permit; go. to this vvebsite:
h s:llde .iic. ov/about/divisionslener .-mirieral-land-resourceslener -mineral-land- ermitsln des-industrial-
ro m and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should -be removed::
Previous legally responsible individual: J I m
First.
4) NEW .OWNER AFFILIATION (legally responsible. for the permit):.
Person legally responsible.for this. permit:
James.
First
Page 1 of 2
McClellan
MI Last
A Martin
M1 Last
5 WU-6WNERAFF[L-0Nov2019

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
5) Reason for this change:
A result of:
If oEher please explain:
EH&S Manager
Title
1293 Glenway Dr.
Mailing Address
Statesville NC 28625
City State Zip
(828 ) 320-0768 [e-mail]
Telephone E-mail Address
t )
Fax Number
Q Employee or management change
Q Inappropriate or incorrect designation before
❑ Other
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
1, James A Martin , 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.
Signature
7-2s-202 1
Date
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 visit the website
at: htt :Ilde .nc. ov/about/divisions/ener -mineral-land-resources/stonnwater
Page 2 of 2
S WU-OWlti ERAFFIL-4Nov2019