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HomeMy WebLinkAboutNCS000304_Owner Affiliation Change_20180323Division of Energy, Mineral, and Land Resources FOR AGENCY USE ONLY DW Land Quality Section I Stormwater Program Year M=th Rwei"e`' Day National Pollutant Discharge Elimination System (NPDES) Energy, Mineral & PERMIT OWNER AFFILIATION DESIGNATION FORM Land Resources ENVIRONMENTAL ONAUTY (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 fill out a Name -Ownership Change Form and submit the completed form with all required documentation. What does "legally responsible individual" mean? The erso i eith r• RECEIVED V n s e. • the responsible corporate officer (for a corporation); 14AR 2 3 2010 • the principle executive officer or ranking elected official (for a municipality, state, fe$&&r te6gAW agency); STORMWATER PERMITTING • 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) Certificate of Coverage Nk f C •S. I Q 10 10 13 10141 1.ii, G G 2) Facility Information: Facility name: G Q rd n Uftr 1 Sfi '- l VS , Inc, Company/Owner Organization: Facility address: Utp o l Lp i_e U Lp .Q CA Address CharMH=e, NG 2 2U9 City State Zip To find the current legally responsible person associated with your permit, go to this website: h=:Hdeg.ne.gov/about/divisions/energy-mineral-land-resources/energy-mineral-land-Re inits/Stormwater-program and run the Permit Contact Summary Report. 3) OLD OWNER AFFILIATION that should be removed: Previous legally responsible individual: il�:�S 1 t 1 �� - bo r- First MI Last I 4) NEW OWNER AFFILIATION (legally responsible for the permit): Person legally responsible for this permit: �-�d r } V a n oyou F1 MI Last Page 1 of 2 S WU-OWNERAFFILr23March2017 NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form (if no Facility Name/Ownership Change) Uicz Praidzn+ Gp_nAG l Mgf, Tide Mailing Address �, N( C1 2X UP City State Zip 0 0�) 59 Lv - OSU Y�d��go cs�nn�raC�ge av Telephone E-mail Address com 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 ClERTIFICATION: 1, P—0d r I QD Co nwo 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. Ot 0,5131 120 ig 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 (919) 707-9220 or visit the website at: hgp:Hdeq nc goy/about/divisions/energy-mineral-land-resources/stormwater Page 2 of 2 SwU-OWNERAF F1L,23 Mar2017