NCG080977_Owner Affiliation Change_20210707

Division of Energy, Mineral, and Land Resources
Land Quality Section 1 Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
Energy, ATrrrrrullS PERMIT OWNER AFFILIATION DESIGNATION FORM
LandRcsourccs 1 14v Ip.7 NMENi RL QUALITY (individual Legally Responsible for Permit)
Use this form if there has been:
FOR AGENCY USEONLY
Date Received
Year
Nlonth
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 (00 Certificate of Coverage or No Exposure
N I C I S N I C I G 10 18 10 19 1 7 17
2) Facility Information:
Facility name: Old Dominion Freight Line - WLM
Company/Owner Organization: old Dominion Freight Line, Inc.
Facility address: 3327 Fredrickson Rd
Address
Wilmington NC 28402
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
h t t p s:llde .nc. ovlaboutldivisionslener v-mineral-land-resourceslene(-mineral-land- permitsln p des-industrial-
rogram and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Terry Hutchins
First M1 I-ast
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: Cecil F. ❑verbey, Jr.
I-'irst Nil Last
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NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form or no Facility Name/Ownership Change)
5) Reason for this change:
A result of:
If o1herplease explain:
Senior VP - Strategic Development
Title
500Old Dominion Way
Mailing Address
Thomasville IBC 27360
city State 'Lip
{ 336 ) 822-5402 [e-mail]
"telephone E-mail Address
Fax Number
0 Employee or management change
❑ inappropriate or incorrect designation before
❑ Other
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
1 Cecil E. Overbey , attest that this application for this change in Owner Affiliation
(person legally responsible for the pen -nit) has been reviewed and is accurate and complete to the best of my
knowledge. 1 understand that if all required parts of this form are not completed, this change may not be
proccssed.
Sign r 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: htt ://de .nc. ov/about/divisions/ener-iTiineral-land-resources/stormwater
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