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HomeMy WebLinkAboutNCG080786_Owner Affiliation Change_20190208Division of Energy, Mineral, and Land Resources Land Quality Section / Stormwater Program K- ra National Pollutant Discharge Elimination System (NPDES) Energy. Mineral& PERMIT OWNER AFFILIATION DESIGNATION FORM land Resources ENVIRONMENTAL OUALfTY (Individual Legally Responsible for Permit) Use this form if there has been: FOR AGENCY USE ONLY Date Received Year Month Day 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 person is either: • the responsible corporate officer (for a corporation); • the principle executive officer or ranking elected official (for a municipality, state, feREG&VLxCD agency); FEB � � 2��� (?�Mg ✓ • the general partner or proprietor (for a partnership or sole proprietorship); • or, the duly authorized representative of one of the above. �DENR-ALAND QUALITY 1) Enter the permit number for which this change in Legally Responsible Individual Y'T lia&l. �ING applies: Individual Permit N I C I S 2) Facility Information: Facility name: Company/Owner Organization: Facility address: (or) Certificate of Coverage N I C I G 0 18 0 7 8 6 GDS - Washington Republic Services of North Carolina, LLC 450 Flanders Filter Rd Address Washington NC 27889 City State Zip To find the current legally responsible person associated with your permit, go to this website: http://deq.nc.gov/about/divisions/enemy-mineral-land-resources/energy-mineral-land-permits/stormwater-pro - ram and run the Permit Contact Summary Report. 3) OLD OWNER AFFILIATION that should be removed: Previous legally responsible individual: Drew First MI 4) NEW OWNER AFFILIATION (legally responsible for the permit): Person legally responsible for this permit: Joseph Page I of 2 First MI Isenhour Last Dehner Last S WU-OWNERAFFIL-23March2017 NPDES Stormwater Permit OWNER AFRLATION DESIGNATION Form (if no Facility Name/Ownership Change) 5) Reason for this change: A result of: If other please explain: General Manager 5111 Chin Page Road Durham City ( 919 ) 433-0914 Telephone (010 ) 991 1036 Fax Number Title Mailing Address NC 27703 State Zip jdehner@republicservices.com E-mail Address r❑ Employee or management change Q Inappropriate or incorrect designation before ❑ Other The certification below must be completed and signed by the permit holder. PERMITTEE CERTIFICATION: I Joe Dehner , 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 requireoarts of this form are not completed, this change may not be 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 Page 2 of 2 S WU-OWNERAFFIL-23Mar2017