NCG110041_Owner Affiliation Change_20200124

Division of Energy,Mineral,and Land Resources FOR AGENCY USE ONLY
Land Quality Section /Stormwater Program Date Received
g Yeaz Month Day
National Pollutant Discharge Elimination System (NPDES)
Energy,Mineral& PERMIT OWNER AFFILIATION DESIGNATION FORM RECEIVED
24
Land Resources
ENVIRONMENTAL OUALIT V (Individual Legally Responsible for Permit)
!AN ZD?1
Use this form if there has been: DENR-LAND QUALITY
NO CHANGE in facility ownership or facility name, but the indiQkiiiiifER PERMITTING
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 (or) Certificate of Coverage or No Exposure
N C S N C G 1 1 0 0 4 1
2) Facility Information:
Facility name: Spring Lake Waste Water Treatment Plant
Company/Owner Organization: Town of Spring Lake
Facility address: 350 Harps St
Address
Spring Lake NC 28390
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
https://deq.nc.gov/about/divisions/energy-mineral-land-resources/energy-mineral-land-permits/npdes-industrial-
program and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: William Zell
First MI Last
4) NEW OWNER AFFILIATION(legally responsible for the permit):
Person legally responsible for this permit: Daniel B Gerald
First MI Last
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NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
Town Manager
Title
300 Ruth St PO Box 617
Mailing Address
Spring Lake NC 28390
City State Zip
(910 ) 436-0241 [e-mail]
Telephone E-mail Address
( )
Fax Number
5) Reason for this change:
A result of: 0 Employee or management change
❑ Inappropriate or incorrect designation before
Li Other
If other please explain:
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
1 Daniel B Gerald ,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 re ' ed parts of this form are not completed,this change may not be
processed.
0
ignature 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
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S W U-O WNERAFFIL-4Nov2019