NCG120047_Owner Affiliation Change_20210602

Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
w National Pollutant Discharge Elimination System (NPDES)
Energy, t finercal & PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resources
ENVAONIONTAL C4VA „Y (Individual Legally Responsible for Permit)
Use this form if there has been:
FOR AGENCY USE ONLY
Date Received
Year
Mondi
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 (far 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 (or) Certificate of Coverage or No Exposure
j
1 12 10 16 4 7
2) Facility Information:
Facility name: Haywood Co -White Oak Sanitary
Company/Owner organization: Santek Environmental of North Carolina LLC
Facility address: 3898 Fines Creek Road
Address
Waynesville NC 28785
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: Ron Vail
First MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: Stephen Slater
First MI Last
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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:
General Manager
Title
1070 Riverside Drive
Mailing Address
Asheville NC 28804
City State Zip
(828 ) 251-4888 [e-mail]
Telephone E-mail Address
f
Fax Number
[✓ Employee or management change
Inappropriate or incorrect designation before
❑ Other
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
1, Stephen Slater , attest that this application for this change in Owner Affiliation
(person legally responsible for thepermit) has been reviewed and is accurate and complete to the best of my
knowledge n e d that if all r uired parts of this form are not completed, this change may not be
proce
2- zi
Signature I 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.ne.gov/about/divisions/energy-mineral-land-resources/stormwater
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S W U-DWNERAFFIL-4Nov2019