NCG190033_Owner Affiliation Change_20220125

Energy. Afteral &
Land Resources
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Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
FOR AGENCY USE ONLY
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PERMIT OWNER AFFILIATION DESIGNATION FORM ���I��
(Individual Legally Responsible for Permit)
Use this form if there has been: JAN 2 5 2022
NO CHANGE in facility ownership or facility name, but LITY
who is legally responsible for the permit has char ERMITfING
If the name of the facility has changed, or if the ownershiv 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
N I C I S
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
(or) Certificate of Coverage or No Exposure
N I C I G 11 19 10 10 13 13
Town Creek Marina - Beaufort
Conscience Bay LLC DBA Town Creek Marina
114 Town Creek Drive
Address
Beaufort NC 28516
City State zip
To find the current legally responsible person associated with your permit, go to this website:
https://deg.ne.gov/about/divisions/energv-mineral-land-resources/energy-mineral-land-perm its/npdes-industrial-
rp ogram and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Charles B TUIeveCh, III
First Mi Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: Steven M TUIeveCh
First MI Last
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NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
Title
114 Town Creek Drive
Mailing Address
Beaufort NC 28516
City State Zip
( 252 ) 728-6111 [e-mail]
Telephone E-mail Address
(252 ) 728-4053
Fax Number
5) Reason for this change:
A result of: ❑ Employee or management change
❑ Inappropriate or incorrect designation before
❑✓ Other
!f other please explain: Change of management duties
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
1, Steven M. Tulevech , 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.
Signature
//L>/�
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/abouvdivisions/energy-mineral-land-resources/stormwater
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