NCG060161_Owner Affiliation Change_20200327

Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
- Jig D
National Pollutant Discharge Elimination System (NPDES)
En t9y.MawtPERMIT OWNER AFFILIATION DESIGNATION FORM
La:td kkesow re)
14 - _ �:_ (Individual Legally Responsible for Permit)
Use this form if there has been:
FOR `AGENCY USE ONLY
Date Received
Year
Month
Day
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.
R'hat 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 (07) Certificate of Coverage or No Exposure
N I C I S N C G 10 16 10 11 6 1
2) Facility Information:
Facility name:
Company/Owner Organization
Facility address:
Clement Pappas NC LLC
Lassonde
125 Industrial Park Rd
Address
Hendersonville NC 28792
Cit% State Zip
To find the current legally responsible person associated with your permit, go to this Nvebsite:
about ch%IMOIIS cncrey-mineral-land-rciourccs,'ener���_ -mineral-land-P�nnitsm (es-in_clustrial_
pr} ogn am and ntn the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION' that should be removed:
Previous legally responsible indit idual: Scott
First
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
Wade
First
Page I of 2
Semper
Ml Last
Anderson
Nil Last
Sk%-U-OkINERAFFiL4Nov2019

7-
NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
5) Reason for this change:
Plant Manager
Title
125 Industrial Park Rd
Mailing Address
Hendersonville NC 28792
City State Zip
(828 ) 693-0711 [e-mail]
Telephone E-mail Address
)
Fax Number
0 Employee or management change
A result of: [3 Inappropriate or incorrect designation before
❑ Other
lfother please c�.rplai�t:
................................................................................................................
The certification below must be completed and signed by the permit holder.
PERAIITTEE CERTIFICATION:
1 Wade Anderson , 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 firm are not completed. this change may not be
processed.
r
Siunature
312- -
Date
PLEASE SEND THE COMPLETED FORiti 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 [phone] or visit the %ti-ebsite
at: IMP: " deq .rtC._w ab0111 divi�ions ltoriii1 k titer
Pace ? of 2