NCS000251_Owner Affiliation Change_20210608

Division of Energy, Mineral, and Land Resources
r ; Land Quality Section / Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
Energy, Mfnerat & PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resources ENVIRONMENTAL QUALITY (Individual Legally Responsible for Permit)
Use this form if there has been:
FOR AGENCY USE ONLY
Dale 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 hi Legally Responsible Individual ("Owner Affiliation")
applies:
Individual Permit
N I C I 5 1 0 10 10 12 15 11
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
(or) Certificate of Coverage or No Exposure
N C G
Conwav Resins Plant
Georgia-Pacific Chemicals LLC
200 Ampac Road
Address
Conway NC 27820
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
https :I/deg .nc. gov/about/divisions/energy-mineral-land-resources/enemy-mineral-land-permits/npdes-industri al-
so am and rein the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual:
Ronald E
First MI
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
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Robert E
First MI
Walls
Last
Dalton
Last
S WU-OWNERAFF,L4Nov2014

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
Plant Manager
Title
P.O. Box 368
Mailing Address
Conway NC 27820
City State Zip
404 343-7545 robert.dalton@gapa(;.com
Telephone )email Address
( 252 ) 585-1754
Fax plumber
S) Reason for this change:
A result of: ❑ Employee or management change
❑ Inappropriate or incorrect designation before
❑ Other
If other please explain: Would like to request that Ronald E. Walls stays as co-owerner if possible
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
1, Robert E Dalton , 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.
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.ne.gov/about/divisions/energy-mineral-land-resources/stormwater
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S WU-OWNERAFFIL-4Nov2019