NCG030588_Owner Affiliation Change_20211020

Division of Energy, Mineral, and Land Resources
Use this form if there has been:
FOR AGENCY USF ONLY
Date Received
Year
Month
Day
NO CHANGE or but s
who s legally responsible for e 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 Certificate of Coverage or No Exposure
8 8
2) Facility Information:
Facility name: ASC/Trion inc.
Company/Owner Organization:
Facility address: 101 McNeill Rd
Address
Sanford NC 27330
City State zip
To find the current legally responsible person associated with your permit, go to this website:
https:Hdcq ne gov/about/divisions/energy-mineral-land-resources/energy-mineral-land-permits/npdcs-industrial-
rp_ograrn and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should he removed:
Previous legally responsible individual: Ron Wenner
First MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: Miguel A Rubio
First MI Last
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SWU-0WN1 RAFFIL4Nov2019

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
Plant Manager
Title
101 McNeill Rd
Mailing Address
Sanford NC 27330
City State Zip
(919 ) 777-6310
Telephone E-mail Address
(
Fax Number
5) Reason for this change:
A result of El Employee or management change
0 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, Miguel Rubio , 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.
10120J2021
Signature
PLEASE SEND THE COMPLETED FORM TO:
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
Date
For more information or staff contacts, please call [phone] or visit the website
at: htt://de .nc. ov/about/divisions/ener -mineral-land-resources/stormwater
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