NCG060026_MONITORING INFO_20171120

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
IV C& b (o 00&
DOC TYPE
HISTORICAL FILE
❑ MONITORING REPORTS
DOC DATE
❑ � 0 r 7 1
YYYYMMDD

r
Division of Energy, Mineral, and Land Resources
Land Quality Section 1 Stormwater Program
National Pollutant Discharve Elimination System (NPDES)
Energy. Mineraf& PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resources
ENVIRONMENTAL QUALITY (individual Legally Responsible for Permit)
FOR AGLNCY USE ONLY
Date Received
Ycar
Month
Day
L.. -L .,'!jL`_'."A1Y
Use this form if there has been: S►G,ii... ,`,aL:R i titi,.,i1 i«
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, 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_
1) Enter the permit number for which this change in Legally Responsible Individual ("Owner Affiliation")
applies:
Individual Permit
NC I 5
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
(Or) Certificate of Coverage
N I C I G 10 16 10 10 12 16
New Colonv Mill Complex
Murphy -Brown LLC
347 Shore Drive
Address
Creswell NC 27928
City State Zip
To find the current legally responsible person associated With your permit. go to this website:
httga/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: Kraig WeSterbeek
First MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
Mark Pahl
First bIl Last
S W U-QV6'NLRiV FI1r23Mareh2017
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NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
Vice Pesident
"title
PO Box 856
Mailing Address
Warsaw NC 28398
City State Zip
( 910) 293-3434 [e-mail]
Telephone E-mail Address
( 910 ) 293-3138
Fax Number
5) Reason for this change:
Employee or management change
A result of: ❑ Inappropriate or incorrect designation before
❑ Other
I(other please explain:
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
1, _ Murphy -Brown LLC . 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
I
Signature Date
PLEASE SEND THE COMPLETED FORM TO:
Division of Energy, Mineral, and Land Resources
Stormwater Program
1612 Mail Service Center
Ralei0h. North Carolina 27699-1612
For more information or staff contacts, please call [phone] or visit the website at:
http_//deg.nc.i�ov/about/divisions/enema -mineral-land-resources/stormwater
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