NCG080944_Owner Affiliation Change_20210218

Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
w National Pollutant Discharge Elimination System (NPDES)
Energy, Mineral& PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resources
-NVIRONMENTAL OIJALITY (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
2) Facility Information:
Facility name:
Company/Owner Organization
Facility address:
(or) Certificate of Coverage or No Exposure
N I C I G 10 18 10 19 4 4
Raleigh Yard
CSX Transportation, Inc.
860 Semart Drive
Address
Raleigh NC 27604
City State zip
To find the current legally responsible person associated with your permit, go to this website:
https://deg.nc.gov/about/divisions/energy-mineral-land-re source s/energy-mineral-land-permits/npdes-industrial-
rp ogram and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Meaghan Atkinson
First MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
Samuel Ross
First MI Last
S WU-O WNERAFF IL4Nov2019
Page 1 of 2

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
Director Environmental Field Services
Title
500 Water Street, J275
Mailing Address
Jacksonville FL 32202
City State Zip
( 904 ) 359-3691 [e-mail]
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 please explain:
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
I Samuel floss , 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.
02/18/2021
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: http://deg.nc.gov/about/divisions/energy-mineral-land-resources/stormwater
Page 2 of 2
S WU-OWNERAFFIL-4Nov2019

ht I
February 4, 2021
Mr. Samuel Ross
Director Environmental Field Services
CSX Transportation, Inc.
500 Water Street, J-275
Jacksonville, FL 32202
Dear Mr. Ross,
500 Water Street
Jacksonville, FL 32202
Phone: [phone]
E-Mail: Nathan _Goldman a,csx.com
NATHAN D. GOLDMAN
Executive Vice President &
Chief Legal Officer
You handle matters pertaining to compliance with Federal, State, and local environmental
laws and regulations. One of your responsibilities is preparing permit applications, variance
requests, report forms and certifications, and such other documents and papers as necessary to
assure compliance with environmental laws and regulations.
Accordingly, I hereby authorize you to sign the necessary environmental documents on
behalf of the Company to carry out your work.
effect.
This authorization is in addition to electronic agency permitting submissions currently in
Sincerely,
yzo , 4'
Nathan D. Goldman