NCG030467_Owner Affiliation Change Request_20211025

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 10/25/2021 12:16:19 PM (Owner Affiliation Change Submission)
Approve by Georgoulias, Bethany A 1/18/2022 9:34:21 AM (Review Assigned to Admin)
* BIMS updated on 1/18/2022.
• Georgoulias, Bethany A assigned the task to Georgoulias, Bethany A 1/18/2022 9:27 AM
• The task was assigned to DEMLR SW Admin 10/25/2021 12:16 PM

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Default Page
NPDES Permit
Number*
Submittor's Name*
Phone Number*
Email Address*
Enter your NPDES stormwater permit number or Certificate of Coverage (COC) number.
NCG030467
NCSXXXXXX or NCGXXXXXX
Please enter your FIRST and LAST name
Jamie Cress
Please enter your phone number
704-483-1900
Any format is fine.
Please enter a valid e-mail address
[e-mail]
A confirmation of submission will be e-mailed to this address.
Need a copy of the Permit Owner Affiliation Designation Form? You must upload a signed copy of that form below.
Questions? Call Bethany Georgoulias at [phone] or e-mail her at [e-mail].
Completed Form Please upload the signed "Permit Owner Affiliation Designation Form"
Upload* Stormwater Owner Name Change.pdf 69.91KB
pdf only

Initial Review
Project ID * Reviewer may revise permit number below if incorrect.
NCG030467

Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
Energy. Mineral a PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resources
EPMROWENTALQUAWY (Individual Legally Responsible for Permit)
Use this form if there has been:
FOR AGENCY USE ONLY
Date Received
Year
Month
Da
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 owner 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.
I) 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 5 N I C I G 10 13 10 14 16 17
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
Wireway/Husky Corp.
WirewaylHusky Corp.
6146 Denver industrial Park Rd
Address
Denver NC 28037
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
https:r'Ideg.nc.gov'about/divisions;'energy.-mineral-land-resources�ene!g,X- ineral-land-permits!npdes-industrial-
rD ogram and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual:
Ronald
First
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
Young
MI Last
Ryan Young
First Mt Last
S WU-O WNERAF FIL4Nov2019
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NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
President
Title
6146 Denver Industrial Park Road
Mailing Address
Deriver NC 28037
City state zip
(704 ) 483-1900 [e-mail]
Telephone E-mail Address
Fax Number
5) Reason for this change:
A result of- r❑ Employee or management change
❑ Inappropriate or incorrect designation before
❑ Other
If other please explain:
The certification below must be completed and signed by the permit holder,
PERMITTEE CERTIFICATION:
1, Ronald Young , 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.
Si re 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: h :Hde .ne. ov/about/divisions/ener -mineral-land-resourcesistormwater
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5 W U-Q W N E RA FFl L-4N o v2019