NCG210134_Owner Affiliation Change_4/9/2020 (2)

Division of Energy, Mineral, and Land Resources FOR AGENCY USE, ONLY
Land Quality Section / Stormwater Program Date Received nay
National Pollutant Discharge Elimination System (NPDES)
P
Energy, mineral & PERMIT OWNER,AFFILIATION DESIGNATION FORM
Land Resources
ENVIRONNENTAI OUALITY (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 forma 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
N C S
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
(or) Certificate of Coverage or No Exposure
`r i s Hardwoods one .
a K a p Drive
Address
1 VCL Nt2877
City State Zip
To find the current legally responsible person associated with your permit, go to this websitc:
https://deg,ne.gov/about/divisions/energy-mineral-land-resources/energy-mineral-land-perm its/npdes-industrial-
ro ram and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Doaq Rp Vie
Fa b MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
Lawr•enct hornpson `M
First MI Last
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