NCG210202_Owner Affiliation Change_20181113

Division of Energy, Mineral, and Land Resources FOR AGENCY USE ONLY
Date Received
Land Quality Section / Stormwater Program Year Month Day
jl
National Pollutant Discharge Elimination System (NPDES)
En ergs--Vineral & PERMIT OWNER AFFILIATION DESIGNATION FORM
L and Resources
ENV!POIJMENTAL OUALITY (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 docum"49f" 1 ,e®
What does "legally responsible individual" mean? NOV 13 20,E
The person is either: DENR-LAND
• the responsible corporate officer (for a corporation); STQRMwATER QUALITY
• the principle executive officer or ranking elected official (for a municipality, state, federal oIVIT 9r 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
N C .S
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
(or) Certificate of Coverage
N ..0 G 2 l 1 0:2—
C 4AI-1 Pionl 4VNj4rS
CiFA.rl t?f0A( #QN1 SK L Ear. 1 tJC
YD-T!r IBIS A101 H
Address
Zj r Al C-
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
http: //deq.nc. gov/about/divisions/energy-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: C4pisroette& A- M ( (_ C—&
First MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
C M00P^1A/C
First M1 Last
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SW U-OVVNE RAFF IL-23March2017

NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
Title - -
0 s.- Ks `/O I S6 uv-f
Mailing Address
L ic.1- I,✓&rA/ i✓G 2�
City State
State Z i p
(9to) H,3 -S7/3 i /Y+oor�.t°i�ckaw,��sv1176wttS
Telephone E-mail Address he {�
(91,v ) 00/,/ - bq l 6
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 CERTIFICATION:
I, J 6ZG /�'loo,>zi.✓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 r
�r
ature 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.nc.gov/about/divisions/energy-mineral-land-resources/stormwater
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SWU-OWNERAFFIL-23Mar2017