HomeMy WebLinkAboutNCS000376_Owner Affiliation Form_20180627ML MMA� Division of Energy, Mineral, and Land Resources F FOR AGENCY USE ONLY
Date Received
AL UTM Land Quality Section / Stormwater Program Year M Day
National Pollutant Discharge Elimination System (NPDES)
PERMIT OWNER AFFILIATION DESIGNATION FORM
(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 ownershio of the facility has changed,
do NOT use this form. Instead, you must till 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 (or)
N C S 0 0 0 13 17 16
2) Facility Information:
Facility name: NC State Univers
Company/Owner Organization: NC State Univers
Facility address: campus Box 8007
Certificate of Coverage
[N Tc G
Address
Raleigh NC 27695
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
littp //deu nc cov/about/divisions/energy-tnineral-land-resources/energy-tnineral land permits/stormwater pram
and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Andy Snead
First Nit Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
Scott Douglass
First Nit Last
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5 W U -O W NERAFF IL -23 March2017
NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
5) Reason for this change:
A result of:
If other please explain:
Vice Chancellor for Finance and Administration
Title
Campus Box 7201, Holiday Hall 106
Mailing Address
Raleigh NC 27695
City State Zip
( ) suouyla')�tuncau.auu
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, Seo -(L Doug lass 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.
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
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S W U -O WNERAFFR.23Mar2017