NCG210450_Owner Affiliation Change_20211123

Division of Energy, Mineral, and Land Resources
Land Quality Section 1 Stormwater Program
N' National Pollutant Discharge Elimination System (NPDES)
I_ric►yy, iNinerul& 'ERMIT OWNER AFFILIATION DESIGNATION FORM
L and Resourr ►•,
:V,a NTA1 -Aloe. (individual Legally Responsible for Permit)
Use this form if there has been;
FOR AGENCY USE ONLY
Rate Received
Ycav
Monde
aay
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 cwnership' of the facility has clanged,
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 Affiliation99)
applies:
Individual Permit (or) Certificate of Coverage or No Exposure
N C I 5 N I C I G 2 11 10 4 5 0
2) Facility Information:
Facility name:
Company/Owner Organization: Enviva Pellets Sampson, LLC _
Facility address: 5 Connector Road US 117
Address
Faison NC 28341
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
https:lldeq.sic.gov/about/divisl.oiis.energy-niiiieial-land-resour-ces/etici-�y-iiiineral-lased-pes-rniis rsl)des-industrial-
rp ogram and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Rickey Searcy
First M1 Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: George Handler
First M! Last
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NPDES Starmwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility. NaniefOwnership Change)
5) .Reason for this change:
A. result of:
If o1hei- plea.ye eTpla1in:
Plant Manager
5 Connector Road I.lS 117
Mailing Addtess
Faisal NC28341
....._�.....__.- Cily� .Slats.........-....___�__—_ Zip.
`984 3 220-5640 [e-mail]
Telephone t -nmil Addmss
Fax Namber
Employee or management change
El lnaipprop6ate or incorrect designation before
❑ Other
The certification below mast be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
I, �� _ attest that this applicaition for this change io Owner Affiliation
(person legal y .L-pQiisible for the pet xiit) has been.re.viewed and is accurate and complete to the best of my
knowledge. I understand tliat if all .required palls uFthis :forin are. not comp] efeti.: Ibis change may not be.
[}TQ. cssed.
Cm [
Sipature Date
PLEASE S.ENI) TIff, CONIPIJE`11,1D FORI'vl'CO:
D:t NILR - Stormwaiter 1'rogra rn
Dopt: of Environmental {duality
16l2 ,'Mail Service .Center
Raleigh, North. Carolina 27699-1612
For more .inbormation or stiff contacts, please call :(919.) 707-9220 or r4s.it the website
at: 1!_ ttp,,6.1 ,e�:l.ti� �}vY-tl�tyaii'al-i rrxdWresi�! rco lstuc'n1�vGttr r
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