NCG060320_Owner Affiliation update_20210310

Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
N r1V_ National Pollutant Discharge Elimination System (NPDES)
Ener9q Vinerai .� PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resour—
2NV (Individual Legally Responsible for Permit)
FOR .AGENCY USE ONLY
Date Received
Year
Month
Day
0,F1.VED
14AR 10 2021
Use this form if there has been: STORI��JVATER PERM
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 "Ie 0v 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) F.oter the permit number for which this change in Legally Responsible Individual ("Owner Affiliation")
applies:
Individual Permit (or-} Certificate of Coverage or No Exposure
N C S I I I I N I C I G b (�
2) Facility Information:
Facility name: �JAW g2w-Nk-Aans • ' 4�1�71y1(1 � (P�l►1j
Company/Owner Organization: Y Y\ M0W -Tdq r {�► pCpG,G,� tSitSlr
Facility address: 30%. 5(AOM-Z� wN
Address
1 � KLI If
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
hops: deq.nc.gox about dictsions energy-mineral-land-resources.ener�p-mineral-land-permits.npdes-industrial-
program and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual:
First MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
First MI Last
Page I of
S WU-OWN E RAF F IL4Nov 2019

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
Title
Mailing Address
Ul' (VGi��i0
City State Zip
Telephone E-mail res
Fax Number
S) Reason for This ehanW:
A result a£: Eno*-yee or rnanageanent change
Inappropriate or incorrect designation before
Other
If other please explain:
The certification below must be completed and signed by the permit holder_
PER11dITTEE CERTIFICATION:
1, 1� S� attest that this application for this change in Owner Affiliation
(person legally responsi e for the permbe it) has en reviewed and is accurate and complete to the best of my
knowledge. 1 understand that if all required harts of this form, are not completed, this change may not be
process
. V. z1
Signature Date
PLEASE SEND THE COMPLETED FORM TO:
DEMLR - Stormwater Program
Dept. of Environrr►ental 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.ne.gov about divisions enemy -mineral -land -resources, storrnwater
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S WU-OWNE RAFFIL-4Vov2019