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HomeMy WebLinkAboutNCG020895_Owner Affiliation Change_20210603Division of Energy, Mineral, and band Resources Land Quality Section / Stormwater Program National Pollutant Discharge Elimination System (NPDES) Energy, Mineral & PERMIT OWNER AFFILIATION DESIGNATION FORM Land Resources ENVIRONMENTAL QUALITY (Individual Legally Responsible for Permit) FOR AGENCY USE ONLY bw Received Year Month llay Use this form if there has been: NO CHANGE in facility ownership or facility name, but the in ividwgl 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 rill 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 (or) Certificate of Coverage or No Exposure N I C I S N C I G 10 12 0 18 19 15 2) Facility Information: Facility name: Company/Owner Organization: Facility address: Aurelian Springs Mine Iluka Resources NC LLC C/O Iluka Resources Inc 12472 St. John Church Road Address Stony Creek Virginia 2 882 City State zip To find the current legally responsible person associated with your permit, go to this website: rp ogram and run the Permit Contact Summary Report. 3) OLD OWNER AFFILIATION that should be removed: Previous legally responsible individual: Clifford W Gillham First MI 4) NEW OWNER AFFILIATION (legally responsible for the permit): Person legally responsible for this permit: Stuart Page 1 of 2 S WU-OWNERAFFIL.4Nov2019 Leine Last NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION Form (if no Facility Name/Ownership Change) Vice President Title 12472 St. John Church Road Mailing Address Stony Creek Va 23882 City State Zip (804 )586-9224 stuart.leinenbach@11uka.com Telephone E-mail Addre s o/SS— Fax Number 5) Reason for this change: A result of: ❑ Employee or management change ❑ Inappropriate or incorrect designation ❑ Other If other please explain: The certification below must be completed and signed by the permit holder. PERMITTEE CERTIFICATION: 1 �'���T G e j 4e.7/J � c / —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. 1 understand that if all required parts of this form are not completed, this change ay not be processed. 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 (919) 707-9220 or visit the we at: httD://deo.nc.eov/about/divisions/enerRv-mineral-land-resources/stormv Page 2 of 2 S WU-OWNERAFFIi-4Nov2019