NCG110128_Owner Affiliation Change_20191230

AILTV-WIFAA
NCDENR
Nm " C-NA DEPARTMENT OF
ENVIRONMENT AND NATURAL RESOURCES
Division of Energy, Mineral and Land Resources
Land Quality Section / Stormwater Permitting Program
National Pollutant Discharge Elimination System (NPDES)
PERMIT OWNER AFFILIATION DESIGNATION FORM
(Individual Legally Responsible for Permit)
FOR AGENCY USE ONLY
Date Received
Year
Month
Day
R1=r,FIhED
DEC 3 0 2019
STORMNIATER PrRI
if NO CHANGE in company or facility ownership or name has occurred
if a Name Change and/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
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 I C I G Q% I fi g
• i, r 1 �I /,
WE
� ON M 1100, �ffd' i � /' .` �: I ill, I
To find the current legally responsible person associated with your permit, go to this website:
http://portal.ncdenr.org/web/Ir/sw-permit-contacts and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: y::Doun (-\L( G&bri el
First I Ml Last
4) NEW OWNER AFFILIATION (Legally responsible for the permit):
Person legally responsible for this permit:
�c (- i GIK -qlk i r
First Ml Last
Title
P© 50, /4a 1
Mailing Address
CIevc_0141\ I,4C_ a7013
City State Zip
(70)a79477'1 elevelandcler0deve-1 ne,01-1
Telephone E-mail Address
(r Ny)a76-007g1
Fax Number
SW U-OW NERAFFI L-22May2014
Page 1 of 2

NPDESStormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
5) Reason for this change:
A result of:
If other please explain:
What does "legally responsible person" mean?
That person is either:
S0 Employee or management change
❑ Inappropriate or incorrect designation before
❑ Other
• 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:
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
ignature 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:
http://portal.ncdenr.org/web/ir/stormwater
Page 2 of 2
SW U-OW NERAFFI L-22May2014