NCG060382_Owner Affiliation Change_20200103

Division of Energy,Mineral,and Land Resources FOR AGENCY USE ONLY
Date Received
Land Quality Section /Storm%ater Program Year Meath Dar
- National Pollutant Discharge Elimination System (NPDES)
Energy.Mineral& PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resources
s,Ivmo1•IENtMouAuTY (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 till out a Name-Ownership Change Form
and submit the completed form with all required documentation.
What does"legally responsible individual"mean? JAN 03 2020
The person is either:
• the responsible corporate officer(for a corporation); DENR-LAND ALITY
• the principle executive officer or ranking elected official(for a municipality,state,fe } ,q rFp ITTING
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 (or) Certificate of Coverage
N C 8 N C Q 0 6 0 3 8 2
2) Facility Information:
Facility name: Statesville Breeder Feed Mill
Company/Owner Organization: Mountaire Farms
Facility address: 2206 West Front St
Addreu
Statesville NC 28687
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-m ineral-land-permits/stormwater-program
and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Carl Heeder
First MI Last
4) NEWOWNER AFFILIATION(legally responsible for the permit):
Person legally responsible for this permit: Randall Caudill
i us( MI Last
Page l of 2
S WU-OWNFRAFFIL-23March2017

Fr
NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
Director of Breeders
_
Title —
PO Box 1320
Mailing Address
Millsboro DE 19966
City State Zip
( )
Telephone E-mail Address
( )
Fax Number
5) Reason for this change:
A result of: 17 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:
1, Randall Caudill ,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. 1 understand that if all required parts of this form are not completed,this change may not be
processed.
� fed ee-c,r4i—s, / a //i 9
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://deq.nc.gov/about/divisions/energy-mineral-land-resources/stormwater
Page 2 of 2
S W U-OWNERAFFt423Mar2o l 7