NCG060209_Owner Affiliation Change_20210726

Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
Energy, Mineral & PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resources
ENVIRONMENTAL QUALITY (Individual Legally Responsible for Permit)
FOR AGENCY USE ONLY
Date Received
Year
Month
Day
RECEIVED
Use this form if there has been:
u--_'!',-,'-LawD Quay
NO CHANGE in facility ownership or facility name, but the individwaIR PERM
who is legally responsible for the permit has changed. LA
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 I C I S I I I I I I I INIC14310 16 0 2 0 9
2) Facility Information:
Facility name: Warsaw Feed Mill
Company/Owner Organization: Murphy -Brown L1-C
Facility address: 2822 NC Highway 24 west
Address
Warsaw NC 28398
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-mineral-land-resources/energy-m ineral-land-permits/npdes-industrial-
ro ram and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Kraig Westerbeek
First MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: John Sargent
First MI Last
Page 1 of 2
S WU-O WNERAFFIIANov2019
G

4
NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
Executive Vice President
Title
PO Box 856
Mailing Address
Warsaw NC 28398-0856
City State Zip
( 910 ) 293-3434 [e-mail]
Telephone E-mail Address
(910 ) 293-3138
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:
1 Murphy -Brown LLC . 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
knovfl4q,dge. I understand that if all required parts of this form are not completed, this change may not be
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-land-resources/stormwater
Page 2 of 2
S WU-0WNERAFFIL-4Nov2019