NCG130056_Owner Affiliation Change_20210628

Energy. Mh7 er ail &
Land Resotirces
ENVIRC)1VINlEIVTAI. QUALITY
N
Division of Energy, Mineral, and Land Resources
Land Quality Section / 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 Deceived
Year I Month Day
CHANGE in facuflot ovsnarar,l10�� �f� `��,IC��DO{�� name, P�a�Q •7G�c� owc9o�oc1���0
iegaHy vaapanaH(2)�a qarr Chs pairmit har,0 chcfinnnaec��a
It 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 aName-Ownership Chancre Form
and submit the completed form with all required di'llcumentafion.v
What does I gally responsible individual" mean?
The person is tither:
P
0
0
the rponsible corporate officer (for a corporation);
the p4nciple 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.
1) Enter the
applies:
permit number for which this change in Legally Res onsible Individual ("Owner Affiliation")
Individual Pennit
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility. address:
Certificate of Coverage or No Expo
Shotwell Transfer Station I!
Shofwell Transfer Station
1506 N. Salem Road
Address
Apex NC 27502
City Stake Zip
To find the current legally responsible person associated with your permit, go to this website:
ht s://de .nc. ov/about/divisions/ever -mineral-land-resources/ever y-nnneral-land-pennits/n
pro,gam and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual; Walter Ha!!, J�'.
First MY Last
4) NEW O
Person le
des-i'ndustrial-
R AFFILIATION (legally responsible for the permit):
gaily responsible for this pemut,*0
Josh Daher
First MI Last
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SWU-0)A7NER-AFF'1L4Nov2019

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
Area President
Title
103 Rupert Road
Mailing Address
Raleigh NC 27603
City State Zip
919 } 876-8485 jdaher@meridianwaste-com
Telephone
Fax Number
5) Reason for this change:
E-mail Address
[� Employee or management change
A result of � 0
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� Josh Daher , 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
rpm
PLEASE SEND THE COMPLETED FORM TO:
DEMLR - Stormwater Prograrn
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:httD:
//dea.nc.�Yov/about/divisians/energy_-mineral-hand-resources/stormwater
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S WT- OWN R .FFIL- No 2 1