NCG190007_Owner Affiliation Chage_20200820

Division of Energy, Mineral,and Land Resources FOR AGENCY USE ONLY
LandQualitySection /Stormwater Program Date Received
L
Year Month Day
National Pollutant Discharge Elimination System (NPDES)
Energy.Mineral& PERMIT OWNER AFFILIATION DESIGNATION FORM RECPR IPD
Land Resources
ENVIRONMENTAL QUALITY (Individual Legally Responsible for Permit)
ALIG 20 2020
Use this form if there has been: DENR-LAND QUALITY
NO CHANGE in facility ownership or facility name, but thiT i IIMEriiRif
RM!TTING
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.
1) Enter the permit number for which this change in Legally Responsible Individual ("Owner Affiliation")
applies:
Individual Permit Certificate of Coverage or No Exposure
N C S N C G 1 9 0 0 0 7
2) Facility Information:
Facility name: Hatteras/CABO Yachts, LLC
Company/Owner Organization:
Facility address: 110 N Glenburnie Road
Address
New Bern NC 28560
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-mi neral-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: Bruce Angel
First MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: Ward Setzer
First MI Last
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. . .
NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
Chief Product Officer
Title
110 N Glenburnie Road
Mailing Address
New Bern NC 28560
City State Zip
(252 )634-4868 [e-mail]
Telephone E-mail Address
( )
Fax Number
5) Reason for this change:
A result of: 0 Employee or management change
❑ 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, WAR/ cti%Zit IT_,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.
-citz ___--.....„.....„ --. '-14- -za
S i unature 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
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