NCG120066_Owner Affiliation_20210614

Division of Energy, Mineral, and Land Resources I FOR AGGNcy us"oNLY
Land Quality Section / Stormwater ProgramK'r-'a v�
National Pollutant Discharge Elimination System (NPDES)
Energy. AtineralR PERMIT OWNER AFFILIATION DESIGNATION FORM 4 2021
Land Resources
„•., r:,,,, «„ n.:a„ ,.,,: {Individual Legally Responsible for Permit) DEN
p� TY
Use this form if there has been: 1: IVI T/NC
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 iris 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 C ISI
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
(or) Certificate of Coverage or No Exposure
N C G
Roaring River Landfill
Wilkes Gounty
PO BOX 389
Address
Roaring River NC 28669
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
littps•//deq nc gov/about/divisions/energy-mineral-land-resources/enemy-mineral-land-permitslnpdes-indtlstrial-
ro ram and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Kent Brandon
First INC Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: John
Pagel of 2
S W U-OW NERAFFILANov2019
in
Yates

NPDES Stormwater permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
County Manager
Title
County Office Building 110 North St
Mailing Address
Wilkesboro NC 28697
City State Zip
(336 ) 651-7300 [e-mail]
Telephone E-mail Address
FaxNumber
5) Reason for this change:
A result of: ® Employee or management change
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, - Teti h n `f a-1 c 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.
AdIlAA ' A �/_
Signatur
6-10-21
PLEASE SEND THE COMPLETED FORM TO:
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
Date
For more information or staff contacts, please call [phone] or visit the website
at: http://deg.nc.gov/about/divisions/energv-mineral-land-resources/stormwater
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