NCG030650_Owner Affiliation Change_20210722

Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resources
aNVIROWMENT ALA AIM (Individual Legally Responsible for Permit)
Use this form if there has been:
FOR AGENCY USE ONLY
Date Received
Year
Month
Day
f
`f�tM' •.
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.
I) Enter the permit number for which this change in Legally Responsible Individual ("Owner Affiliation")
applies:
Individual Permit
N I C S
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
(or) Certificate of Coverage or No Exposure
N I C I G Q 3 10 16 15 10
CommScope- Claremont
CommScope, Inc.
3642 US Hwy 70 East
Address
Claremont NC 28610
City State zip
To find the current legally responsible person associated with your permit, go to this website:
https://deg.nc. gov/about/divisions/energy-mineral-land-resources/energy-mineral-land-permits/npdes-industrial-
rp o am and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Jeff Dixon
First MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: Terry Richardson
First MI Last
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NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
5) Reason for this change:
A result of:
If other please explain:
VP Operations, NAR
Title
6519 CommScope Road
Mailing Address
Catawba NC 28609
City State Zip
( 828 ) 241-6195 [e-mail]
Telephone E-mail Address
Fax Number
❑✓ 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, Terry Richardson , 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.
7, 2-1 - Ll
Signature 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: http://deg.nc.gov/about/divisions/energy-mineral-larld-resources/stormwater
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