NCG210134_Owner Affiliation Change_4/9/2020

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
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le
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S t4+ 0. J Mailing Address
NC 28�nq
City State Zip
59u- J044 InfhoWron32G ggmad- Cob)
Telephone E-mail Address
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Fax Number
5) Reason for this change:
A result of: 9 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:
I, LdwrfJX C 'nFA On IV!, 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 ate not completed, this change may not be
processed. ;
a n
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 [phone] or visit the website
at: http://deg.ne.gov/about/divisions/energy-mineral-Iand-resources/stormwater
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