NCG030642_COMPLETE FILE - HISTORICAL_20170919

STORMWATER DIVISION CODING"SHEET
NCG PERMITS .
PERMIT N0.
%V cs o u-
DOC TYPE
HISTORICAL FILE
❑ MONITORING REPORTS
DOC DATE
❑
YYYYM M DD

Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
Energy, Mincrnl PERMIT OWNER AFFILIATION DESIGNATION FORM
La rl Resources
PIVInO:011ENIALRUAJ11Y (Individual Legally Responsible for Permit)
Use this form if there has been. -
FOR AGENCY USE ONLY
Date Received
Year
Montle
I}a
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" ruean?
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.
I) Enter the permit number for which this change in Legally Responsible Individual ("Owner Affiliation")
applies:
Individual Permit (or) Certificate of Coverage
N C S :N .0 G° 6 Z
2) Facility Information:
Facility name: QxyC(TNE A_}ryj-2,r
Company/Owner Organization:
Facility address: Ck.N W&Y _
Address
I0w •, /V t Ze6sy
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
htt ://de .nc. ov/about/divisions/ener -mineral-land-resources/ener -mineral-land- ermits/stoiTnwater- ro ram
and run the Permit Contact Summary Report,
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Jr3t VY 'A'i a 101A z-
First Mi Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
Llfft k6wc:�14
First Mt Last
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S WU-OWNERAFH-23March2o 17

NPDES Stormwater Permit OWNER AFF'ILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
F H-S Cc�'-r4 ; N - 3ter
Title
Mailing Address
City State Zip
4Z %— G 45`19 L PAAlae-CcL -1Z +.r�5v j+-;J0j .
Telephone E-mail Address Gc)#Vl
Fax Number
5) Reason for this change:
A result of: ,� Employee or management change
❑ Inappropriate or incorrect designation before
❑ Other
1f other please explain:
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
1, _ls d.�j - , 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 al l required parts of this form are not completed, this change may not be
processed.
J/K2 'e 2/)�J/ 7'
Signature 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://deq.nc.gov/about/divisioiis/energy-mineral-land-resources/stormwater
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S W U-O WNERAFF IIr23 Ma r2017