NCG160223_Owner Affiliation Change_20210823

Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
r 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 1 SI IDLY
Dole Receiked
Year
Monlh nary
NO CHANGE in facility ownership or facility name, tttlt the irtdivir,,
who is I", ally 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, iederal 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
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 I 1 6 0 12 12 13
FPT Infrastructure
FPT Infrastructure
401 Old Highway 52 South
Address
Mount Airy NC 27030
City State Zip
To find the current legally responsible person associated with your pennit, go to this website;
ham,: Je�I.n Llv ahutlt dig i,iolt. enrr;�miltcr:tl tntlmr��ource, cncr �-mineral-ltutciJ�ertnits sit)Jes-indusu•ial-
)rogram and run the Permit Contact Summary Report,
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Jonathan
First MI
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: Bart
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Simmons
Last
Pharr
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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:
Vice President
Title
401 Old Highway 52 South
Mailing Address
Mount Airy NC 27030
City State Zip
( 336 ) 786-8244 Bart. Pharr@FPTlni rastructure.com
'Telephone F-mail Address
(336 ) 786-8712
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 Bart Pharr , 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. 1 understand that if all required parts of this form are not completed, this change may not be
processed.
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:Tidal.nc.�oviahoutldivisionsr'entty�'-mineral-land-rest�urces stormwatcr
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