NCS000583_Owner Affiliation Change_20201112

Division of Energy, Mineral, and Land Resources
Land Quality Section 1 Stormwater Program
M National Pollutant Discharge Elimination System (NPDES)
Energy, Mineral & PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resources
ENVIFONNENTAL QUALITY (individual Legally Responsible for Permit)
Use this form if there has been:
FOR AGENCY USE ONLY
Date Received
Year
Month 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.
1) Enter the permit number for which this change in Legally Responsible Individual ("Owner Affiliation")
applies:
Individual Permit
N I C I S 1 O 1 O 1 O S 81 3
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
(or) Certificate of Coverage or No Exposure
N I C I G
Metallix Refinin
Metallix Refining
251 Industrial Boulevard
Address
Greenville NC 27834
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
h s://de .ne. ov/about/divisions/ener -mineral-land-resources/ener -mineral-land- ermits/n des-industrial-
rp ogram and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual:
John
First
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
Santos
MC Last
Patrick Fee
First MI Last
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NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
Di cc or of Onr t s
Title
251 Industrial Boulevard
Mailing Address
Greenville NC 27834
City State Zip
252 ) 544-5335 atrickf metallix.com
Telephone E-mail Address
Fax Number
5) Reason for this change:
® Employee or management change
A result of: ❑ Inappropriate or incorrect designation before
❑ Other
If other Tease explain:
................................... ........................................
........................................
The certification below must be completed and signed by the permit holder.
pERMITTEE CERTIFICATION:
I, Patrick Fee attest that this application for this change in owner Affiliation
(person legally responsible for the permit) has been reviewed
� not completed, this change may not be is accurate and comlete to the best of
knowledge. 1 under s d that if all required parts of this f
processed.
Date
Signature
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 :Ilde .nc. ovlaboutldivisionslener -mineral-land-resources/stormwater
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S W11-0WNERAFFIL-4Nov2019