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HomeMy WebLinkAboutNCG030004_Owner Affiliation Change_20211217Division of Energy, Mineral, and Land Resources Land Quality Section / Stormwater Program K`ra National Pollutant Discharge Elimination System (NPDES) Energy, Mineral & PERMIT OWNER AFFILIATION DESIGNATION FORM Land Resources ENVWO"EN(AL GUAWY (Individual Legally Responsible for Permit) Use this form if there has been: FOR AGENCY USE ONLY Date Received Year h9onth7 Dap 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 SI 2) Facility Information: Facility name: Company/Owner Organization Facility address: (or) Certificate of Coverage or No Exposure N I C I G 10 13 10 10 10 14 Duff -Norton Duff -Norton 9415 Pioneer Ave Suite 100 Address Charlotte NC 28273 City State "Lip To find the current legally responsible person associated with your permit, go to this website: https://deg.nc.gov/about/divisions/energy-mineral-land-resources/energy-mineral-land-peimits/npdes-industrial- ro ram and run the Permit Contact Summary Report. 3) OLD OWNER AFFILIATION that should be removed: Previous legally responsible individual: John D Mulvey First MI Last 4) NEW OWNER AFFILIATION (legally responsible for the permit): Person legally responsible for this permit: Erika Strand First MI Last Page I of 2 S WU-OWNF.RAFFIL4Nov2019 NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION Form (if no Facility Name/Ownership Change) Global EHS Manager Title N49W13650 Campbell Dr Mailing Address Menomonee Falls WI 53051 City State "Lip (716 )689-5635 Erika.Strand@cmworks.com Telephone E-mail Address Fax Number 5) Reason for this change: A result of: Q Employee or management change Inappropriate or incorrect designation before ❑ Other if outer please explain: The certification below must be completed and signed by the permit holder. PERMITTEE CERTIFICATION: I, 54t4--, I t► c-, , 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 hat 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 (919) 707-9220 or visit the website at: http://deg.nc.gov/about/divisions/energy-mineral-land-resources/stormwater Page 2 of 2 SNvl'-OWNERAFFIL-4Nov2019