NCG020628_Owner Affiliation Change_20200825

Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
Energy. Mineral & PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resources
ENVIRONMENTAL GUAUTY (Individual Legally Responsible for Permit)
Use this form if there has been:
FOR AGENCY USE ONLY
Date Received
Year
M..,I,
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:
0 the responsible corporate officer (for a corporation);
0 the principle executive officer or ranking elected official (for a municipality, state, federal or other public
agency);
0 the general partner or proprietor (for a partnership or sole proprietorship);
0 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
W
2) Facility Information:
Facility name:
Company/Owner Organization
Facility address:
(or) Certificate of Coverage or No Exposure
*10 12 10 16 12 18 1
SCD Mine
Sampson County Disposal, LLC
7434 Roseboro Highway
Address
Roseboro NC 28382
City State zip
To find the current legally responsible person associated with your permit, go to this website:
https:Hdeg.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: Bryan Wuester
First M1 Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
Joseph Smith
First Mi Last
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SWU-OWNERAFFILANov2019

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
5) Reason for this change:
&M MR Me
If rather please explain:
PERMITTEE CERTIFICATION:
Landfill Manager
Title
7434 Roseboro Highway
Mailing Address
7434 Roseboro Hwy NC 28382
City State Zip
910 ) 525-4132 [e-mail]
Telephone E-mail Address
(910 ) 525-4150
Fax Number
[Z] Employee or management change
0 Inappropriate or incorrect designation before
El Other
1, Joseph Smith 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 under that if all required parts of this form are not. completed, this change may not be
processed. I r
�- d 5- do -)-I
Signature Date
PLEASE SEND THE COMPLETED FORM TO:
DEMLR - Storrawater 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: http://deg.nc.gov/about/divisions/energy-mineral-land-resources/stormwater
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