NCG210033_Owner Affiliation Form_20180627

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NCDENR
ENVIRONMENT AND N TURAL R-oURGE5
Division of Energy, Mineral and Land Resources FOR AGENCY USE ONLY
Date Received
Land Quality Section / Stormwater Permitting Program Yea, 1 Mond, Day
National Pollutant Discharge Elimination Systern (NPDES)
PERMIT OWNER AFFILIATION DESIGNATION FORM
(Individual Legally Responsible for Permit)
;i Ci'-1A!V(Sr ` fn ",,eyroparyy or facility rawoetship or name has occurred.
clivIlor Ownership Transfer at the facility has prompted this change, do
NO thi-s fr;rm. You must fill out tho Nance -Ownership Change Form. and provide a//
necessary supporting documentation instead.
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:
Company/Owner Organization;
Facility address:
(or) Certificate of Coverage
N C G 1 1 a e 3 3
of 1. CQ.sca r Mo.vrc ?IV vJOdd
`3C Sc ries[(
_ 30 � Cc�rt+.ikti 'fid
Address
movtCL&r-c- WC 2 7559
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
http_//porlal.nc(lenr.or<,,/web/Ir/svv-permit-ct)iitact,> 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:
SWU-OWNERAFFIL-22May2014
3ricavl
MI
Last
C14VI
First MI Last
QS�c�n
7=t-%ip MAUI Lit
'I ule
�i O i3 ox 111 4
Mailing Address
5c 29 7 O G
City State Zip
( X03) 325- 3181 ria C @ 8C c----%
Telephone E-mail Address
Fax Number
Page 1 of 2

NPDESStormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
5) Reason for this change:
A result of; Employee or management change
❑ 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 CERTI FICATION:
I, & , 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 ynderstanc 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 Permitting Program
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
For more information or staff contacts, please visit our website:
Ilil� IJ�rr{ rt;il.�accic-r�r.c>i.�4��1S11.rl5rorin4w;itr-r
Page 2 of 2
SWU-OWN ERAFFI L-22May2014

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
Page 1 of 2
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
Page 2 of 2
SM-OWNERAFFI L-22May2014