NCS000369_Owner Affiliation Change_20201119

Division of Energy, Mineral, and Land Resources
Land Quality Section / Stm•mwater Program it
( %
National Pollutant Discharge Elimination System (NPDES)
Energy Mineral & PERMIT OWNER AFFILIATION DESIGNATION FORM
L and Resources
ulvuunluculsl aueuly (Individual Legally Responsible for Permit)
Use this form if there has been:
POR AGENCY USE ONLY
Dale Received
Yenr
March Un
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 respmrsible individuaP' 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 orother public
agency);
• the general partner or proprietor (for a partnership or sole proprietorship);
• or, the duly authorized representative of one of the above.
I) Enter the permit number for which this change in Legally Responsible Individual ("Owner Affiliation")
applies:
hidividual Permit
UUMM
2) facility Information:
Facility name:
Company/Owner Organization:
Facility address:
(or) Certificate of Coverage or No Exposure
N C G
Butler -Warner Generetlon Plant
Fayallevllle Public Works Commission
2274 Custer Avenue
Address
Fayetteville NC 28312
City Slate zip
To find the current legally responsible persmt associated with your permit, go to this website:
hops://deg.nc.Qov/about/d i v i sions/enereY-m i neral-land-resources/enerav-mineral-I and -permits
program and run the Permit Cmrtnet Summary Report,
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Marlon
4) NSW OWNER AFFILIATION (legally responsible for the permit):
Person
legally responsible for this permit:
Noland
pan
LflSI
William C May
Pirsl MI Lnsl
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S Wll-OWNERAPPIL4Nov2019

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
Power Plant Manager
Title
PO Box 1089
Mailing Address
Fayetteville NC 28302-1089
City State Zip
( 910 ) 2234814 [e-mail]
Telephone E-mall Address
Fnx Number
5) Reason for this change:
A result of; ❑Employee or management change
0 Inappropriate or incorrect designation before
❑ Other
If other please explain:
..................................................................................................................
The certification below must be completed and signed by the permit holder.
Y)✓RMITTCC CCRTIFICATION:
1, 91 �.% � - t ♦.two �, 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.
Sign re Date
YLEAS); S)CNll TH); COMPL);T>;D 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: httu://deq.no.stov/about/divisions/energv-mineral-land-resources/stormwater
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