NCG030630_Owner Affiliation Change_20220120

Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
energy. Mineral & PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resources
ENVIRONMENTAL QUALITY (Individual Legally Responsible for Permit)
FOR AGENCY USE ONLY
Date Received
Year
I Month
I Day
RECERVED
Use this form if there has been: AAR-LAND QI mo
NO CHANGE in facility ownership or facility name, but the inaNNUMPERMI'
who is legally responsible 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
N I C' S I I I N I C I G 10 13 0 6 3 0
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
HARPER CORPORATION OF AMERICA
HARPER CORPORATION OF AMERICA
11625 STEELE CREEK ROAD
Address
CHARLOTTE NC 28273
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
https: //deg. nc. goy/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: RONALD H KLUTTZ
First MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
RONALD L HARPER
First MI Last
Page 1 of 2
5 WU-OWNERAFF1L4Nov2019

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
OWNER
Title
PO BOX 38490
Mailing Address
CHARLOTTE NC 28278
City State Zip
(704 ) 588-3371 LEE.HARPER®HARPERCORPORATION.COM
Telephone E-mail Address
(704 )588-3819
Fax Number
❑ Employee or management change
❑ Inappropriate or incorrect designation before
® Other
LEGAL NAME CHANGE
The certification below must be completed and signed by the permit holder.
PERMITTE/E CERTIFICATION:
I, R062 ` e_ 4gel- 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.
-�ignattu'e — - --
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.ne.gov/about/divisions/energy-mineral-land-resources/stormwater
Page 2 of 2
S WU-OWNERAFFIL-4Nov20l9