NCG020217_Owner Affiliation Change_20200817

Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
K_Z National Pollutant Discharge Elimination System (NPDES)
Eneryy. Ntineral t3< PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resources
PWRONWNTAI_ ounutr (Individual Legally Responsible for Permit)
Use this form if there has been:
FUR AGENCY USF. ONLY
Date Received
Year
Momh
Day
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 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.
I) 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 I C I G O 12 10 12 1 7
2) Facility Information:
Facility name: Pine Hall Brick Co -Galloway M
Company/Owner Organization: Pine Hall Brick Co Inc
Facility address: Price Rd sr 1171
Address
Madison NC 27025
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
https://de .nc. ov/about/divisioiis/ener7 -mineral-land-resources/ever -mineral-land- ermits/n des-industrial-
ro gram and run the Permit Contact Summary Report,
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Preston McMillan
First MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: Geoffrey Roberson
First MI Last
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NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
5) Reason for this change:
A result of:
If other please explain:
Technical Services Director
Titic
PO Box 836
Mailing Address
Madison NC 27025
City State Zip
(336 )548-6007 groberson 9 pinehallbrick.com
Telephone E-mail Address
336 548-1837
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, Sa,1 attest that this application for this change in Owner Affiliation
(person legally r sponsible 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.
A5et�� A - J�'_ /7 ?id2o
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: htt://de .nc. ov/about/divisions/ener -mineral-]and-resources/stormwater
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