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HomeMy WebLinkAboutNCS000458_Owner Affiliation Change_20210621Division 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 (919) 707-9220 or visit the website at: http: deq.nc.l;ov about/divisions, energy -mineral -land -resources. stormwater Page 2 of 2 S WU-0WNERAFFIL-4Nov2019