NCG030265_Owner Affiliation Change_20210708

Energy, Mineral &
Land Resources
ENVIRONMENTAL QUALITY
Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
PERMIT 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
!DECEIVED
NO CHANGE in facility ownership or facility name, but the indAND
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 Aftiliation")
applies:
Individual Permit (or) Certificate of Coverage or No Exposure
N I C I S 10 3 10 12 6 5 N I C I G
2) Facility Information:
Facility name: Dave Steel Company, Inc
Company/Owner Organization: Non -Government Organization
Facility address: 40 Meadow Rd
Address
Asheville NC 28803
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
https:Hdeg.nc.gov/about/divisions/energy-mi neral-land-resources/energy-mineral-land-permits/npdes-i ndustrial-
rogram and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual:
Allan
First M1
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: Lorie
First MI
Clontz
Last
Brown
Last
ING
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NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/ONrnership Change)
5) Reason for this change:
A result of.
If other please explain:
Safety Leader
Title
443 Belle Isle Rd
Mailing Address
Georgetown SC 29440
City State Zip
(828 ) 707-3114 ([e-mail]
Telephone E-mail Address
(828 1252-0041
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, Lorie Brown , 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.
Ig"u ._o
Signature
�) f k I a�
ate
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-land-resources/stormwater
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