NCS000423_Concord Owner Affiliation Designation Form_20201105

Division of Energy,Mineral, and Land Resources FOR AGENCY USE ONLY
Land Quality Section/Stormwater Program
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National Pollutant Discharge Elimination System (NPDES) Nov o 5 2020
Energy.Mineral& PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resources ENVIRONMENT Al QUALITY (Individual Legally Responsible for Permit) Dr NR-LAND QUALITY
MWATER PE MITTING
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.RECEIVE
If the name of the facility has changed, or if the ownership of the facility has 449VOcb 2029
do NOT use this form. Instead,you must fill out a Name-Ownership Change Form
and submit the completed form with all required documentation. DENR-LAND QUALI
STORMWATER PERMIT (Nr=
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 (or) Certificate of Coverage or No Exposure
N C S 0 0 0 4 2 3 N C G
2) Facility Information:
Facility name: Concord City-Small MS4
Company/Owner Organization:
Facility address: 35 Cabarrus Ave W
Address
Concord NC 28025
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-mineral-land-resources/energy-mineral-land-perm its/npdes-industrial-
program and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Brian W. Hiatt
First MI Last
4) NEW OWNER AFFILIATION(legally responsible for the permit):
Person legally responsible for this permit: Lloyd Wm. Payne
First MI Last
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NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
City Manager
Title
PO Box 308
Mailing Address
Concord NC 28026-0308
City State Zip
(704 ) 920-5209 [e-mail]
Telephone E-mail Address
(704 )795-0404
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, Lloyd Wm. Payne , ,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.
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:, ature 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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S WU-OWNERAFFIL-4Nov2019