NCG120110_Owner Affiliation Change_20210628

Energy, Min eral &
LatidResources
ENVIRONMENTAL QUALITY
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Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
PERM�T 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
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iegafly respons'b�a for i�ha p��rr�u� Pna,,� �G������c90
ff 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 Change Form
and submit the completed form with all required documentation.
What does "legally responsible individual" mean?
The personi's either:
1)
• the re ponsbleicorporate officer (for a corporation);
• theprinciple executive off cer or ranking elected official (for a municipality, slate, federal or ether public
agency);
• the general partner or proprietor (fox a partnership or sole proprietorship);
• or, the duly authorized representative of one of the above.
Ender the permit number for which this change in Lee
ally Responsible IndiVjdual (��Dwner Affliatiorn99�
applies: I
Individual Permit
2) Facility Information:
Facility name:
Company/owner Orgamzation:
Facility address:
Certificate of Coverage or No Expo
Shotwell Landfill, Inc.
Shotwell Landfill, Inc.
4724 Smithfield Road
Address
Wendell N C 27591
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
ht s:Ilde .nc. ov/about/divisions/ener -mineral-land-resources/ever -mineral-land- ermits/n
]progam and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual:
4) -NEW OVVNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
S WU-OWNERAFFIL4Nov2019
sure
des -industrial -
Walter Hall, Jr.
First MI Last
Josh Daher
First MI Last
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NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
5) Reason for this change:
A result of:
If other please explain:
Form (if no Facility Name/Ownership Change)
Area President
Title
103 Rupert Road
Mailing Address
Raleigh NC 27603
City State Zip
919 ) 876-8485 [e-mail]
Telephone
Fax Number
E-mail Address
� Employee or management change
Inappropriate or incorrect designation before
❑ Other
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The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
� Josh Daher ,attest that this application for this change in Owner Affliction
(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
Date
PLEASE SEND THE COMPLETED FORM TO:
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Censer
Raleigh, North Carolina 27699-1612
For more information or staff contacts, please call [phone] or visit the webszte
at: htfia://dea.nc.Rov/about/divisionslener --mineral-land-resources/stannwater
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S WJ^ WNE AFFIL-4No 2 1