NCG210202_Owner Affiliation Change_20210505

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Energy, Mineral &
L and Resources
Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
PERMIT OWNER AFFILIATION DESIGNATION FORM
ENVIRGNr1ENTAL 1iUALITY k111V1V1UU►11 L.W$J1111Y RVLFJV11X11W1V IV1 rV11111L)
FOR AGENCY USE ONLY
Date Received
Year
Month
Day
Use this form if there has been: 14AY 05 2021
NO CHANGE in facility ownership or facility name, but the '@9404Y Z
who is legally responsible for the permit has char�@WWATERPERMI TNG
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 Pennit (or) Certificate of Coverage or No Exposure
N I C I S I I N I C I G N JE 11 2 0 3
2) Facility Information:
Facility name: Blum, Inc.
Company/Owner Organization:
Facility address: 7733 Old Plank Rd.
Address
Stanley NC 28164
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-resources/energy-mineral-land-pennits/npdes-industrial-
program and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Karl Rudisser
First MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: Shannon Lafferty
First MI Last
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NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
General Manager
Title
7733 Old Plank Rd.
Mailing Address
Stanley NC 28164
City State Zip
(704 ) 827-1345 [e-mail]
Telephone E-mail Address
( )
Fax Number
5) Reason for this change:
El 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 Shannon Lafferty , 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
nrncPccarl
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
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S WU-0WNERAFFIL-4Nov2019