NCG120023_Owner Affiliation Change_20200630

FOR AGENCY USE ONLY
Date Received
Year
Mouth Day
Use this form if there has been:
NO CHANGE in facility,
air 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.
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.
t) 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 G 1 12 10 lo 2 3
2) Facility Information:
Facility name: Meadowview (toad County Landfill
Company/Owner Organization: Onslow County
Facility address: 415 Meadowview Road
Address
Jacksonville NC 28585
City State Zip
To find. the current legally responsible person associated with your permit, go to this website:
https:/Ideg.iic.gov/about/divisions/eiiel.,qy-iiiiiiei'al-land-resources/elierti`I-miiiei-al-land-pei,iniis/nudes-i:tdustri.al-
prograrn and run the Permit Contact Summary Report,
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: David S Bost
First M1 Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: Melissa H Moore
First MI Last
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NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Naive/Ownership Change)
5) Reason for this change:
A result of:
If other please explain:
Solid Waste Director
Title
415 Meadowview Road
Mailing Address
Jacksonville NC 28540
City State Zip
(910 ) 989-2107 [e-mail]
Telephone E-mail Address
(910 ) 455-7878
Fax Number
Employee or management change
® Inappropriate or incorrect designation before
® Other
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
1, _ [[)�Jattest 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.
I �V'_ d
Signature
06/30/2020
PLEASE SEND THE COMPLETED FORM TO:
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
Date
For more information or staff contacts, please call [phone] or visit the website
at: hap: //d e.nc. gov/about/divisions/ener<g-mineral-land-resources/store-rwater
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