NCG020916_Owner Affiliation Change_20201001

Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
® National Pollutant Discharge Elimination System (NPDES)
& PERMIT OWNER AFFILIATION DESIGNATION FORM
(Individual Legally Responsible for Permit)
FOR M.ENCY USH ONLY
Dnu Received
Year klondi I)ay
Use this form if there has been:
NO CHANGE in facility ownership or facility name, but the individual
who is legally responsible for the permit has changed.
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" meant?
The person is either:
• tie responsible corporate officer (for a corporation);
• the principle executive officer or ranking elected official (for a municipality, state, federal or other public
a Pnrvl.
• tlhe general partner or proprietor (for a partnership or sole proprietorship):
• o� , the duly authorized representative of one of the above.
1) Entetthe permit number for which this change in Legally Responsible Individual ("Owner Affiliation")
app s:
Individual Permit (ur) Certificate of Coverage or No Exposure
N I C I S T1N G G 0 2 10 9 1 6
2) Facil,ty Information:
Fa 'lity name: Boardman Mine
Cn pany/Owner Organization: Sunset Farms, Inc.
Facility address: Macedonia Church Road
Address
Evergreen NC 28438
City State 7_ip
To find the current legally responsible person associated with your permit, go to this website:
littps://de nc. ov/about;'clivisions/ener -mineral-land-resources/energy -mineral-]and- etmits,'n des-i ndustri a I -
prop,ram. id run the Permit Contact Summary Report,
3) OLD OWNER AFFILIATION that should be removed:
Pre 'ous legally responsible individual: Daniel Horne
First Nil Last
4) NEW WNER AFFILIATION (Iegally responsible for the permit):
Pers n legally responsible for this permit: Marc Cox
First MI Last
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1 Marc
(person
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NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Channe)
Manager
Title
303 South Maultsby Street
Mailing Addre„
Whiteville NC 28472
City State Zip
910 ) 625-5012 [e-mail]
Telephone E-mail Address
(910 ) 640-2609
Fax Number
for this change:
ilt of: Employee or management change.
❑ Inappropriate or incorrect designation before
❑ Other
rr please explain:
ification below must be completed and signed by the permit holder.
CERTIFICATION:
attest that this application for this change in Owner Affiliation
ly responsible for the permit) has been reviewed and is accurate and complete to the best of my
I understand that if all required parts of this form are not completed, this change may not be
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 :I/de .iie. ov/about/divisions/ener -mineral-land-resources/stoiinwatei,
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