NCG060238_Owner Affiliation Change_20180129

Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
- National Pollutant Discharge Elimination System (NPDES)
Energy, Mineral & PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resources
ENVIRONMENTAL QUALITY (Individual Legally Responsible for Permit)
Use this form if there has been:
FXV
FOR AGENCY USE ONLY
Date Received
Year Month Day
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 mclivinuar, mean.
The person is either:
JAI 29 2913
• the responsible corporate officer (for a corporation);
• the principle executive officer or ranking elected official (for a municipality, stlfi-�Fbh@ iViublic
agency); STOE3�11 ATER I�ERMITTV831
• 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 (or)
N I C I S
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
Certificate of Coverage
N ICIG O 1610 2 3 8
Candor Feed Mill
Mountaire Farms
203 Morris Farm Rd
Address
Candor NC 27229
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
http://deg.nc. gov/about/divisions/enercy-mineral-land-resources/energy-mineral-land-permits/stormwater-program
and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual:
First
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
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S WU-OWNERAFFIL-23March2017
First
Tirrel
MI Last
Paulakuhn
MI Last

NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
5) Reason for this change:
A result of:
If otherplease explain:
VP of Live Operations
Title
PO Box 1320
Mailing Address
Millsboro DE 19966
City State Zip
( 302 ) 934-3453 jpaulakuhn@mountaire corn
Telephone E-mail Address
Fax Number
❑ Employee or management change
® Inappropriate or incorrect designation before
❑ Other
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
I, J l rA%_L a k U 4l , attest that this application for this change in Owner Affiliation
(person legally iesponsible for the p rmit) 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.
L a.0 16
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:
http://deg .ne. gov/about/divisions/energy-mineral-land-resources/stormwater
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S WU-OWNERAFFIL-23Mar2017