NCG100079_Owner Affiliation Change_20210623

Energy,, Mineral &
Land resources
ENVIRONMENTAL QUALITY
Division of Energy, Mineral, and Land Resources
Land Quality Section I Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
PERMIT OWNER AFFILIATION DESIGNATION FORM
(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.
ff the namer of the facility has changed, or ff the ownership of the facility has changed,
do NOT use this form. Instead, you must rill out aName-Ownership Change Form
and submit the completed form with all required documentation.
What does "legally responsible individual" mean?
The person is either4b
:
• the responsible corporate officer (fox a corporation);
4
• the principle executive officer or ranking elected official (for a municipality, sate, federal or other Public
agency};
• the general partner or proprietor (for a partnership or sole proprietorship);
• or, the duty authorized representative of one of the above.
1) Enter the permit number for which this change in Legally Responsible Individual ("Owner Affiliation")
apples:
Individual Permit
2) Facility Information..
Facility name:
Company/owner Organization:
Facility address:
(or) Certificate of Coverage or No Exposure
Green's Auto Salvage, LLC
2646 N C Hwy 222 East
Address
Fremont NC 27830
City State Zip
To find the current legally responsible person associated with your permit, go to thsiwebsite:
naps:/ /aeq.nc.gov/anoutiaivisions/ener-minerai-Tana-resourcesiener-minera-iana- ermits/n
- program and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATIUN that should be removed:
- ..
des -industrial -
Previous legally responsible individual: Herbeft H Green
First MI Last
4) NEW OWNER AFFECTATION (legally responsible for the permit):
Person legally responsible for this permit:
SVVU-WN1AFELN21
Debbie G. Lassiter
First M1 Last
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