NCG050153_COMPLETE FILE - HISTORICAL_20180404

FR D
STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
/V CJ d I Cj 3
DOC TYPE
HISTORICAL FILE
❑ MONITORING REPORTS
DOC DATE
❑
YYYYMMDD

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Division of Energy, Mineral, and Land Resources
,Land Quality Section / Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
PERMIT OWNER AFFILIATION DESIGNATION FORM
(Individual. Legally Responsible for Permit)
Use this form if there has been:
FOR AGENCY USE ONLY
Data Received
Y2
Month
I Da
,NO CHANGE in facility ownership:or facility name, but the iandividu_ al
who isAegally responsible for the permit has changed.
If the .name .of the facility has changed, or if the owner 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 documentatiorR EC p I f E
What does O'legally responsible individual" mean? APR 0 4 Z018
The person is.either: CENTRAL FILES
• the responsible corporate officer (for a corporation); WR F
QN
• the principle executive officer or -ranking eiected.official (for a municipality, state, federa�bt'. bth P ft�� c
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 (o,) Certificate of Coverage
N C S N `C G O 5 0 t 5 3
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
Cascades Tissue Group -North Carolina, a division of Cascades Holding US Ina
Cascadesinc.
PO Box 578 805 Midway Rd.
Address,iW+
Rockingham North Cad 28379
City State Zip
To find the current legally responsible. person associated with your permit, go to this'website:
lit tp://deq.nc.govlabout/divisions/energy=mineral-land-resources/energy=mineraHand-perm its/stormwater-program
and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: EPIC Taylor
Vj First. MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: MI y
First MI Last
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NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
Guillaume Bouvier- VP of Operations
J Title
V 77,Marie-Victodn Blvd.
Mailing �r�c�4
Candiac(QuefJec, Carte J5R1C2
�i City State Zip
Telephone E-mail Address
�- -Y A'
, )
Fax Number %ur 1l�Villef- ��lif �r�c].�'
3) Reason for this change: \ r
�.1
�]✓ Employee or management change
A result of: [ 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, Mickey Lee 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 are not completed, this change may not be
processed.
03/02/2018
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 littp://deg.nc.gov/about/divisions/energy--iiiiiCal' ldiid-rdsbd fces/storliiwater,
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