NCG210338_Permit Owner Affiliation Designation Form_20200630

Division of Energy,Mineral,and Land Resources FOR AGENCY USE ONLY
Date Received
Year Month Day
Land Quality Section/Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
Energy.Mineral& PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resources I\/E D
ENVIRONMENTAL DUALITY (Individual Legally Responsible for Permit)
Use this form if there has been: JUN 3 0 ?flit
NO CHANGE in facility ownership or facility name, but the individual
utNK-LAND QUALI
who is legally responsible for the permit has changed:
TORMWATER PERMIT INC
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 2 1 0 3 3 8
2) Facility Information:
Facility name: Lampe&Malphrus Lumber Company-Peedin Rd.Planar Mill
Company/Owner Organization: Lampe&Malphrus Lumber Company
Facility address: 37 East Peedin Rd.
Address
Smithfield NC 27577
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: James Malphrus
First MI Last
4) NEW OWNER AFFILIATION(legally responsible for the permit):
Person legally responsible for this permit: Will Lampe
First MI Last
Page 1 of 2
S WU-OWNERAFFIL4Nov2019

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
Vice President
Title
P.O. Box 150
Mailing Address
Smithfield NC 27577
City State Zip
(919 ) 934-6152 [e-mail]
Telephone E-mail Address
(919 )934-0134
Fax Number
5) Reason for this change:
0 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, James S. Malphrus . 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
pro/ ./2----5/2-6.265
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:http://deq.nc.gov/about/divisions/energy-mineral-land-resources/stormwater
Page 2 of 2
S WU-O WNERAFFIL-4Nov2019

AMES S.MALPHRUS Lampe & Malphrus ROSS W. Secretary
President/CEO Y
919-934-6152 919-938-4900
Lumber Company
member
$PI B® Post Office Box 150, Smithfield, NC 27577
June 12, 2020
CERTIFIED MAIL
RETURN RECEIPT REQUESTED
7017 1000 0000 1900 2404
Ms. Annette Lucas, P.E.
Stormwater Program Supervisor
1612 Mail Service Center
Raleigh,NC 27699-1612
RE: Permit Owner Affiliation Designation Form
Stormwater General Permit and Certificate of Coverage (COC)NCG210338
L&M Lumber Company—Peedin Rd. Planar Mill
Dear Ms. Lucas:
Lampe & Malphrus Lumber Company is submitting a Permit Owner Affiliation Designation
Form to change the legally responsible official for the above referenced COC. The Form
removes James S. Malphrus as the owner affiliation and replaces with Will Lampe.
Should you have any questions concerning this submittal, please call me at [phone], or
Tim Monroe of Leaf Environmental & Engineering, P.C. at [phone].
Sinc ely,
L ALPHRUS LUMBER COMPANY
ames S. Malphrus
President & CEO
Enclosures