NCG080641_Owner Affiliation Change_2010921

Energy, Mineral &
Land Resources
ENVIRONMENTAL QUALITY
Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
FOR AGENCY USE ONLY
Date Received
Year
Month
Day
National Pollutant Discharge Elimination System (NPDES)
PERMIT OWNER AFFILIATION DESIGNATION FORM SEP 21 2021 �"t`^'
(Individual Legally Responsible for Permit)
Use this form if there has been:
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 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 N I C I G 10 18 0 16 1 4 1 1
2) Facility Information:
Facility name: Mebane Stopping Center
Company/Owner Organization: T A operating LLC
Facility address: 500 Buckhorn Rd-140 85 Ex
Address
Mebane NC 27302
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 ogram and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Robert
First
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
Josh
First
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Canders
MI Last
Cordell
MI Last
S WU-OWNERAFFIL4Nov2019

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
District Manager
Title
229 Lone Star Way
Mailing Address
Cary NC 27519
City State Zip
( 317 ) 719-7606 [e-mail]
Telephone E-mail Address
Fax Number
5) Reason for this change:
0Employee or management change
A result of: ❑ Inappropriate or incorrect designation before
❑ Other
If other please explain:
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
I Josh Cordell , 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.
N�=Cu - (pIZ1 IZpzl
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•//deq nc gov/about/divisions/energy-mineral-land-resources/stonnwater
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S WU-OWNERAFFIL-4Nov2019