NCG090034_Owner Affiliation Change_20221102

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Division of Energy, Mineral, and Land Resources
:om,n.,r,n0 a -. Land Quality Section / Stormwater 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 AGENC' UM: ONLY
Dal,• Received
Year
Month Day
ownershipNO CHANGE in facility
• is legallyes♦ • e for the pernift 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 (lor a municipality, stale, 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 10 19 10 10 3 4
Inolex
Inolex
12345 Steele Creek Road
Address
Charlotte NC 28273
City. State zip
To find the current legally responsible person associated with your permit, go to this wcbsite:
ln(ps:/1dcq.nc.gov/s%vi Navigate to the "NPDES Industrial Program" section and run the Stormwater Permit
Contact Summary Report for your permit number.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Alanna
First MI
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: Ron
First MI
Smith
Last
Lopez
Last
Page I of 2
Last revised 20 Feb 2022

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
Director of Operations
7 ille
12345 Steele Creek Road
Mailing Address
Charlotte NC 28273
City Stale "Lip
(980 ) 770-4923 [e-mail]
Telephone L-snail Address
( )
Fax Number
5) Reason for this change:
A result of: ❑✓ Employee or management change
171 Inappropriate or incorrect designation before
❑ Other
/f other please explain:
The certification below must be completed and signed by the permit holder.
Note: 40 CFR 122.22(c) requires an original signature (not digital)
PERMITTEE CERTIFICATION:
1, Ron Lopez 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
he pro d.
11-2-22
i� nature Date
PLEASE SEND THE ORIGINAL SIGNED COPY OF THE COMPLETED
OWNER AFFILIATION CHANGE FORMTo:
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.nc.g)ov/lSw
Per NC General Statute .143-215.6I3 (i), any person who knowingly makes any false statement, representation, or
certification in any application, record, report, plan, or other document tiled or required to be maintained under this
Article or a rule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars (S 10,000).
Page 2 of 2
last reviwd 20 Feb 2022