NCG080664_Owner Affiliation Change_20220124

Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
Energy' M`neral & PERMIT OWNER AFFILIATION DESIGNATION FORM
Landl2esources EPIVIRt7NMEN7Al QUALITY (Individual Legally Responsible for Permit)
Use this form if there has been:
FOR AGENCY USE ONLY
Date Received
Year
Month
Day
NO CHANGE in facility ownership or facility name, but the individual
who is legally responsib.le 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 rill 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
INICIS1 N C I G 10 18-]0[ 6F6 14]
2) Facility Information:
Facility name: Transflo Charlotte East Terminal
Company/Owner Organization: TRANSFLO Terminal Services Inc
Facility address: 601 N Hoskins Rd
Address
Charlotte NC 28216
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
https:Hdeg.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: Jan M Barnes
First MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: Ryan E Prewitt
First MI Last
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NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
5) Reason for this change:
A result of:
If other please explain:
Manager Chemical Safety
Title
500 Water St J975
Mailing Address
Jacksonville FL 32202
City State Zi"
(606 ) 344-5531 [e-mail]
Telephone E-mail Address
(904 ) 245-2257
Fax Number
❑✓ Employee or management change
❑ Inappropriate or incorrect designation before
❑ Other
...................................................................................................................
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
I, Ryan Prewitt , 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. understand that if al equired parts of this form are not completed, this change may not be
proc
Signature V 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/energy-mineral-land-resources/stortnwater
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