NCG160235_Owner Affiliation Change_20220207

Division of Energy, Mineral, and Land Resources
Land Quality Section I Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
Energy, Mineral PERMIT OWNER AFFILIATION DESIGNATION FORM
L and Resotarces
FNVJW)T2MF-NTA1 «jALnY (Individual Legally Responsible for Permit)
Use this form if there has been:
HMO M,44VAI
FOR AGENCY USE ONLY
Date Received
Year
Month
Day
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 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 Affiliation")
applies:
Individual Permit (or) Certificate of Coverage or No Exposure
I I I I N C G 1 6 10 2 13 5
2) Facility Information:
Facility name: Reeves Construction Co - Bonds Asphalt Plant
Company/Owner Organization: Reeves Construction Company
Facility address: 7139 Weddington Rd NW
Address
Concord NC 28027
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
https;lideq.nc.govlabc�utldivis€onsletretgyaninaral-land-resources/energy-mineral-land-pert its/iipdes-industrial-
rop gram and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual:
Colton
First
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
Ginn
MI Last
Michael L O'Shields, Jr.
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:
Assistant Secretary
Title
18606 Northline Dr
Mailing Address
Cornelius NC 28031
City State Zip
(864 ) 612-6020 [e-mail]
Telephone E-mail Address
(704 ) 892-4794
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, Michael L. O'Shields Jr. , 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 forth are not completed, this change may not be
processed.
Signaf411
22,
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: littp://deq.ne.gov/about/divisiotis/ener-iiiineral.-laaad-resourcesistori-nw iter
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