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HomeMy WebLinkAboutNCG030170_Owner Affiliation Change_20210706Division of Energy, Mineral, and Land Resources Land Quality Section 1 Stormwater Program National Pollutant Discharge Elimination System (NPDES) Energy. Mineral & PERMIT OWNER AFFILIATION DESIGNATION FORM Land resources EH VIROW E N tAL OVAL PTY (Individual Legally Responsible for Permit) Use this form if there has been: FAR AGENCY USE ONLY Date Received Year Mooch 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 in Legally Responsible Individual ("Owner Affiliation") applies: Individual Permit N C S 2) Facility Information: Fac i 1 ity name- Company/Owner Organization: Facility address: (or) Certificate of Coverage or No Exposure N C G {} 3 0 1 T 0 IMC-MetalsAmerica, LLC 135 Old Boiling Springs Road Address Shelby NC 28152 City State Zip To find the current legally responsible person associated with your permit, go to this website: liltps:lldeq.nc.gov/abc)utldivisioilslener�L1,V-mineral-lanci-resoureeslenCT i mineral -land- erniits/n des-industrial- rogjp[n and run the Permit Contact Summary Report. 3) OLD OWNER AFFILIATION that should he removed: Previous legally responsible individual: Richard W Strachan First MI Last 4) NEW OWNER AFFILIATION (legally responsible for the permit): Person legally responsible for this permit: Brian Freeman Page I oft First y11 Last 5 WU-OWNERAFF[L-0Nov2019 NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION Form (if no Facility Name/Ownership Change) Technical Manager Title 135 Old Boiling Springs Road Mailing Address Shelby NC 28152 City State 'Lip (704 ) 4716550 freeman@imc-ma.com Telephone E-mail Address Fax Number S} Reason for this change: A result of:❑ Employee or management change Inappropriate or incorrect designation before ❑ Other If olher please explain: The certification below must be completed and signed by the permit holder. PERMITTEE CERTIFICATION: 1, Brian Freeman , 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 re . d parts of this form are not completed, this change may not be processed. July 6, 2021 ignature 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: l}tti):/Idea.rlc.Lov/abotit/divisioiis/enert-v-m i iieral-land-resources/stormwater Page 2 of 2 S W U -D W N ERAFF1 L-4Nov2019