NCS000458_Owner Affiliation Change_20210621

Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
Energy. Mine. PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resource,
ENVIRONMENTAL QUALM (Individual Legally Responsible for Permit)
Use this form if there has been:
FOR AGENCY USE ONLY
Date 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 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
N I CIS 10101014 8
2) Facility Information:
Facility name:
Company Owner Organization:
Facility address:
(or) Certificate of Coverage or No Exposure
N I C I G
-Town of "oilts
occ Quern c
V llo ffish 9-004
Address
AoM Mt Its NC_ 28348
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
littps:lldeg.nc.gov/about/divisionsienergy-mineral-land-resources energy-mineral-land-pennitslnpdes-industrial-
rp ogram and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: McAksso.. ? N6m5
First MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
SCoIR W ' Aes-zar05
First MI Last
S W U-O WNE R AF F IL4Nov2014
Pagel of 2

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
-own M&nQ4er
Title
577o 1 Afish evad
Mailing Address
Hope M i Its WC 9048
City State Zip
(`��o )�42�-�a4 srisit xrosCo? 6dA040pem�llscom
Telephone E-mail Address
(910 ) 42Li - 4gm
Fax Number
5) Reason for this change:
�mployee 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, _ ]COW CS-1,0,60 S , 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.
�Vature 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: deq.nc.l;ov about/divisions, energy -mineral -land -resources. stormwater
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S WU-0WNERAFFIL-4Nov2019