NCG120071_Owner Affiliaiton Update_20210322

Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
Energy, Mineral PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resources
E7NVWONME.Nr.AL QUALITY (Individual Legally Responsible for Permit)
Use this form if there has been:
FOR AGENCY USE ONLY
Date Received
Year
Month
Day
s'c1=CE1VED
MAR Z 4 2021
QUALITY
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 ouName-Ownership Cha r
and submit the completed form with all required documeni�
What does "legally responsible individual" mean? InA1% 5M" &..-
The person is either: OENR-L�N0 QUALITY
• the responsible corporate officer (for a corporation); STORMWATER PERMITTING
• 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 C S
2) Facility Information:
Facility name:
Company/Owner Organization
Facility address:
(or) Certificate of Coverage or No Exposure
N C G 1 2 0 lo 7 11
Cherokee County Municipal Solid Waste Landfill
Cherokee County
10160 US Hwy 19
Address
Marble NC 28905
City State Zip
To find the current legally responsible person associated with your pennit, go to this website:
https://deg.nc. gov/about/divisions/energy-mineral-land-resources/energy-mineral-land-pennits/npd es-i iidustri al-
rp ogram and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Brian Dillon
First MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: Robert Ward
First MI Last
Page 1 of 2
S WU-O WNERAFFIL4Nov2019

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
5) Reason for this change:
A result of:
If other please explain:
Solid Waste Director
Title
75 Peachtree Street
Mailing Address
Murphy NC 28906
City State Zip
( 828 ) 837-2621 [e-mail]
Telephone
Fax Number
E-mail Address
❑✓ Employee or management change
® Inappropriate or incorrect designation before
❑ Other
...............................................................................................................
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICfATI/ON:
I, A?42 31f9ir W� , 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.
N
Signature
i� cyL
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-0WNERAFFIL-4Nov2019