NCG060007_Owner Affiliation Form_20171101

Division of Energy, Mineral, and Land Resources FOR AGENCY USE ONLY
Land Quality Section 1 Stormwater Program Date Received
L
+' Q g Year Month I Da
_ National Pollutant Discharge Elimination System (NPDES)
Energy. Mineral & PERMIT OWNER AFFILIATION DESIGNATION FORM
L and Resources
ENVIRONMENTAL OUALITY (individual Legally Responsible for Permit)
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 form. Instead, you must rill out a Name -Ownership Change Form
and submit the completed form with aff 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:
CompanylOwner Organization:
Facility address:
(or) Certificate of Coverage
N C G 0 6 0 0 0 7
Keystone Foods
Marfrig� _
227 Eauitv Drive
Address
Reidsville NC 27320
City state zip
To find the current legally responsible person associated with your permit, go to this website:
http://deg.nc.gov/about/divisions/energy--mineral-land-resources/enera-mineral-land-permits/storrnwater-pro ,ram
and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual:
Tom F Harris
First MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit
SWU-0WNERAFFIL-23Mar0i2017
Louis G Hughes
First MI Last
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NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
General Manager
Title
227 Eauity Drive
Mailing Address
Reidsville NC 27320
Cite State Zip
[e-mail]
[phone] m
1'elephone E-mail Address
(3361349-2940
Fax Number
5) Reason for this change:
A result of:
/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, ior_, attest that this application for this change in Owner Affiliation
(person legally respons le 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:
Division of Energy, Mineral, and Land Resources
Stormwater Program
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
For more information or staff contacts, please call [phone] or visit the website at:
httpl de .nc.gov/about/divisions/energy-mineral-land-resources/stormwater
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SWU-OW NERAFFIL-23Mar2017