NCG030234_Owner Affiliation Change_20210719

Division of Energy, Mineral, and Land Resources
NtZ
Land Quality Section / Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
Energy. Mineral & PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resources
E6NIP0,13.tENTAGQUALITY (Individual Legally Responsible for Permit)
Use this form if there has been:
rOR AGGNCY USG ONLY
Da tc Reccived
Year
M011th 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 (or) Certificate of Coverage or No Exposure
N C S III I I Nj C I G 0 13 10 12 13 14
2) Facility Information:
Facility name: Bendel Tank and Heat Exchanger LLC.
Company/Owner Organization: Group
Facility address:: 4823 N. Graham
Address
Charlotte NC 28269
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
program and run the Permit Contact Summary Report,
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: William M Beaver
First MT Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
Greg Ezzell
First M1 Last
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NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
President and Chief Operations Officer
Title
14527 U.S. Highway 64 Alternate West
Mailing Address
Rocky Mount NC 27804
city slate zip
(252 ) 446-4357 [e-mail]
Telephone C-mail Address
(252 ) 446-1374
Fax Number
5) Reason for this change:
A result of: El 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 Greg Ezzell
,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
Imowledge. I understand that if all required parts of this forra are not completed, this change may not be
processed.
06/13/2021
Signature Date
PLEASE SEND THE COMPLETED FORM TO:
DEMLR - Storrnwater 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: http://deg.iic.gov/about/divisioiis/energy-miiioral-laud-resources/stormwater
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