NCG060369_Owner Affiliation update_20210310

Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
4 PERMIT OWNER AFFILIATION DESIGNATION FORM
(Individual Legally Responsible for Permit)
Use this form if there has been:
FOR AGENCY USE ONLY
Date Received
Y:ar 'Month Day
' 1/FD
HIAR 10 2021
DENR-LAND QUAL
STORMiWATER 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 faeikty 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.
Wbat does "legally responsible individual" mean?
The person is either:
a 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
N C S
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
(or) Certificate of Coverage or No Exposure
N C I G 'O 1 (0 0 1 3 I (p
°eta FGt►� S — �ls 6r
Address
.QGw15 N Ci
City State zip
To find the current legally responsible person associated with your permit, go to this website:
https: deg.nc.gov about dig isions energy -mineral -land -resources energy -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: ?MtmhS(e�
First M1 Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: VA(A k 17k W r Ae
First M1 Last
NG
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S WU-OWNE RAFF11-4NoN 2019

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
Titre
Mailing Address
City State Zip
Telephone I E-mail AJdress
Fax Plumber
5) Reason d®r this changt:
Emptoyee or mat;agement change
result of: Inappropriate or incorrect designation before
Other
#'aher please explain:
The certification below must be completed and signed by the permit holder.
PE]R!MITT�E2),E CERTIFICATION:
I, (I��A 'J� I S( attest that this application for this change in Owner Affiliation
(person legally responsible fd 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.
4/
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: deg.nc.gov about divisions-.'enemy-mineral-land-resources/stormwater
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