NCG030677_Owner Affiliation Change_20210730

Division of Energy, Mineral, and Land Resources
s Land Quality Section / Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
t eryy; ri=n 1 PERMIT OWNER AFFILIATION DESIGNATION FORM
Land kesources.
V IRON ENTAIAVAulY (Individual Legally Responsible for Permit)
Use this form if there has been:
FOR AGENCY USE ONLY
Date Received
Year
I Month 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 rill 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
.$ I
ll
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
(or) Certificate of Coverage or No Exposure
l
Xt
Address
City State zip
To find the current legally responsible person associated with your permit, go to this website:
https:/ldeg.ne.gov/about/divisions/energyr-mineral-land-resources/energy-mineral-land-permits/ pdes-industrial-
ro ram and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: -s
First MI Las
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person Iegally responsible for this permit: Im nm &)b
�(1(1�
Fil st MI Last
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NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
Title
Mailing Address
YC Y1 Ky-
City state Zip
TTele�phone 1j &s
mail Addres
��
Fax Number
5) Reason for this change:
A result of- Employee or management change
Inappropriate or incorrect designation before
❑ Other
If other please explain:
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
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.
0
j — (--�] IN Ian I
Signatur 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: ttp:eg.no.gov/abo,ut/division s/energy-mineral-land-resources/stormwater
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