NCG140435_Owner Affiliation Change_20220204

Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
,4
National Pollutant Discharge Elimination System (NPDES)
;Energy. J fines)& PERMIT OWNER AFFILIATION DESIGNATION FORM
L.rxnditesntrtees Fn'NRiRC3TiN7fKT'PA•:3L?�i_P1Y (individual Legally Responsible for Permit)
,
Use this form if there has been:
FOR AGEN Y USE ONLY
Date eived
Year I bjonth llay
i
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 (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
N. I C I S
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
(or) Certificate of Coverage or No Exposure
N C G 1 14 10 14 3 5
American Concrete, Inc.
American Concrete, Inc.
2698 Mount Home Church Road
Address
Morganton NC 286,�55
City State I zip
To find the current legally responsible person associated with your permit, go to this website:
https:Hdeg.nc.gov/about/divisions/energy-mineral-land-resources/energy-mineral-land-permits
program and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual:
Gary
First MI
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: Kevin
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First Ml
Stroupe
L st
Stroupe_
Last
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NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Faeility Name/Ownership Change)
5) Reason for this change:
A result of:
If other please explain:
Owner
Title
2698 Mount Home Church Road
Mailing Address
Morqanton NC 28655
City State Zip
(828 ) 443-0034 [e-mail]
Telephone E-mail Address
828 1438-1023
Fax Number
0 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 Kevin Stroupe , 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 underst d that if all required parts of this form are not completed, this change may not be
processed.
Signature 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 [phone] or visit the website
at: http://deq.ne.gov/aboutidivisions/energy-mineral-land-resotirces/stormwater
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