NCG210288_Owner Affiliation Change_20180627

A 4 0
NCDENR
NORTH CAROLINA DEPARTMENT OF
IAND N AT RESOURCES
Division of Energy, Mineral and Land Resources FOR AGENCY
Date Received
Land Quality Section / Stormwater Permitting Program Yeat Month Dav
National Pollutant Discharge Elimination Systern (NPDES)
PERMIT OWNER AFFILIATION DESIGNATION FORM
(Individual Legally Responsible for Permit)
r "
NO 4 01 col',at.ai aoy or fac lify ownership or r7ame has occurred.
<tf,- Name Change rang/or Ownership Transfer at the facility has prompted this change, do
NOT use this form. You must fill out the Name -Ownership Change Form and provide all
ecessary supporting documentation instead.
1) Enter the permit number for which this change in Legally Responsible Individual ("Owner
Affiliation") applies:
Individual Permit
N I C S El
2) Facility Information:
(or) Certificate of Coverage
N I C I G 12 1 0 12$ 1S
Facility name: Uc�,sc born �� 'tKr�r iJe rad�c�s
Company/Owner Organization: e- L
Facility address: 1 000 fk ivs
Address
vo be �-o Nc 2X5 3
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
htt :/;' orlal.ncdenr.or17/web/Ir/sw- ertuit-contacts and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual:
First MI Last
4) NEW OWNER AFFILIATION (Legally responsible for the permit):
Person legally responsible for this permit: —&-10 V-1 C,.I 4 -
First MI Last
I VI o0.►n a r
'I le
0 1116
Mailing Address
L 2 qa
City State Zip
0103) ZS - 31 O i l�r�av) CuL&Cn cd wi
Telephone E-mail Address
Fax Number
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SWU-OWNERAFFIL-22May2014

NPDESStormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
5) Reason for this change:
Employee or management change
A result of; ❑ Inappropriate or incorrect designation before
❑ Other
If'other please explain:;:
What does "legally responsible person" mean?
That 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 that person above.
The certification below must be completed and signed by the permit
holder.
PERMITTEE CERTIFICATION:
I, k,A A Va— G , 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. A /Jll
Signature Date
.....................................
PLEASE SEND THE COMPLETED FORM TO:
Division of Energy, Mineral and Land Resources
Stormwater Permitting Program
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
For more information or staff contacts, please visit our website:
htt�l Fc�r�u I.i ictiiciu�orul����hlh'lstor'tt'IFviitrr
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SM-OWNERAFFI L-22May2014