NCG080760_Owner Affiliation Change_20211129

Division of Energy, Mineral, and Land Resources FOR AGINCV �,sr.c� 1.s
Land Quality Section 1 Stormwater Program hate Recei ed
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-N National Pollutant Discharge Elimination System (NPDES)
tandl?Energv. sa Mineral PERMIT OWNER AFFILIATION DESIGNATION FORM
Lui'icf Rpsatrrc•r�
`'"' `'' ' ' (individual Legally Responsible for Permit)
Use this form if there has been:
NO CHANGE in fac:lliiy 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 ownP 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 genera] partner or proprietor (for a partnership or sole proprietorship);
• or, the duly authorized representative of one of the above.
l) Enter the permit number for which this change in Legally Responsible Individual ("Owner Affiliation')
applies:
Individual Permit
N C 5
2) Facility Information;
Facility name:
Company/Owner Organization:
Facility address:
(tijJ Certificate of Coverage or No Exposure
N C G 0 8 0 7 6 0
A8F Freight System, Inc,
1165 NC Hwy fib S
Address
Kernersville NC 27284
City State 'Lip
To find the current legally responsible person associated with your permit, go to this website:
htt s://de .nc. ov/about/divisions/ener -mineral-land-resources/ener -mineral-land- ermits/n des-industrial-
ro ram and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Mark McMinn
First M 1 last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: Matthew Godfrey
First MI Last
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S WU-WVNERAFFi1,4Nov2019

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Nance/Ownership Change)
Vice President
Title
3801 Old Greenwood Road
Mailing. Address
Fort Smith AR 72903
City State zip
(479 ) 785-6000 [e-mail]
Telephone E-mail Address
Fax Numher
5) Reason for this change:
A result of: 0 Employee or management change
Inappropriate or incorrect designation before
❑ Other
if other please explain:
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
I, Matthew Godfrey , 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 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:'//deg.ne.gov/about/divisions/energ (-mineral-land-resourceslstormwater
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S wU-DW iVt.RAFFiLANv■•?Ol 9