NCG190074_Owner Affiliation Change and SW Permit DOSA_20220311

Division of Energy, Mineral, and Land Resources
Land Quality Section 1 Stormwater Program
K.
w National Pollutant Discharge Elimination System (NPDES)
Energy, Mineral & PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resources
ENVIRONMENTAL aVALITY (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 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 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:
0 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 I S N I C I G 11 9 0 0 7 4
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
MarineMax - Wrightsville Beach
MarineMax East, Inc.
130 Short Street
Address
Wriahtsville Beach NC 28480
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
htt s://de .ne. ov/about/divisions/ever-inineral-land-resources/ever -mineral-land- ermits/n des-industrial-
rp ogram and run the Permit Contact ,Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: William H McGill
First MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: Michael H Mcl_amb
First MI Last
Page 1 of 2
S WU-0 WNERAFFILANov2019

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
President
Title
2600 McCormick Drive, Ste 200
Mailing Address
Clearwater FL 33759
City State Lip
{ 727 ) 228-8086 [e-mail]
Telephone E-mail Address
(727 ) 524-3954
Fax Number
5) Reason for this change:
A result of: ❑� Employee or management change
Inappropriate or incorrect designation before
❑ Other
If other please explain:
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
1, Michael H. McLamb , 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 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: htt :Hde .nc. ov/about/divisions/ener -mineral-land-resources/stormwater
Page 2 of 2
S WU-o WNEItAFFIL-4Nov2019

NC Department of Environmental Quality
h'
Division of Energy, Mineral and Land Resources
NORTH CAROUNA
Erwim"melital Quality
Stormwater Permit Delegation of Signature Authority Form
Directions are in red.
This form shall be used to delegate signature authority from the permit Owner (Permittee) to
another party. Only the Responsible Official defined below may submit permit applications and
reports required by the permit (such as Data Monitoring Reports and Annual Reports) until this
form is completed and submitted to the DEMLR Stormwater Program. Please note that delegating
signature authority does not relieve the Permit Owner from the responsibility for permit
compliance.
=> The permit Owner is the legal entity to which/whom a permit has been issued, and may be an individual
or an organization such as a company or government agency. Every Owner is required to have a
Responsible Official who meets the legal signature authority requirements in 40 CFR 122,22, summarized
below:
• For a corporation, the Responsible Official shall be a president; secretary, treasurer, or vice-
president in charge of a principal business function, or another individual who performs similar
functions for the corporation, or the manager of one or more manufacturing, production, or operating
facilities who is authorized to make management decisions about the facility operation.
• For a partnership or sole proprietorship, the Responsible Official shall be a general partner or the
proprietor, respectively; or
• For a municipality, State, Federal, or other public agency, the Responsible Official shall be either a
principal executive officer [City/County Manager] or ranking elected official [Mayor].
=> Even if delegated signatory authority has been delegated to another individual, the Responsible Official
retains responsibility for compliance with permit conditions.
Permittee:
MarineMax East, inc.
Permit Number:
NCG190074
Responsible Official Title:
President
Email Address:
[e-mail]
Phone:
�727-228-8086
Mailing Address:
2600 McCormick Drive, Ste 200
City.,
Clearwater
State:
IFL
I Zip:
133759
Stormwater Delegation of Signature Authority Form
Page 1

A. Persons to Receive Signatory Authority
=> The signatures of the persons listed below indicates their acceptance of signatory authority.
Delegated Party Name:
Carrington smart
General Manager
Delegated Party Title:
Delegated Party Organization:
MarineMax East, Inc.
Email Address:
[e-mail]
Phone:
910-208-4852
Mailing Address:
130 Short Street
City:
Wrightsville Be ch
State:
NC
I Zip:
28480
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
c
Delegated Party Name:
Delegated Party Title:
Delegated Party Organization:
Email Address:
Phone:
J State: Zip:
Mailing Address:
City:
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
Delegated Party Name:
Delegated Party Title:
_
Phone:
_
State: Zip:
Delegated Party Organization:
Email Address:
Mailing Address:
City:
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
Delegated Party Name:
Delegated Party Title:
Delegated Patty Organization:
Email Address:
Phone:
Mailing Address:
City:
State:
Zip:
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
Stormwater Permit Delegation of Signatory Authority Form
Page 2

B. Responsible Official Signature
The Responsible Official, as identified in accordance with 40 CFR 122.22, is the appropriate
individual with the authority to sign and submit reports for the organization.
As the Responsible Official, I, Michael H. McLamb
have the authority to enter into this Agreement for
MarineMax East, Inc.
(Owner/Organization Name).
(printed name),
I request that the DEMLR Stormwater Program include the persons listed in Part A of this form
signatory authority for the above -named permit.
I acknowledge that I, and the persons listed in Part A of this form work at/for my organization
and have authority to act as a signatory for purposes of the NCDEQ's electronic document
systems.
By submitting this application, I, Michael H. McLamb (printed name),
have read, understand, and accept the terms and conditions of the stormwater permit(s) for
which I am the Responsible Official.
Responsible'Official Signature
President
Title
Date
Stormwater Permit Delegation of Signatory Authority Form
Page 3

Georgoulias, Bethany
From: Chris Ruhlin <[e-mail]>
Sent: Friday, March 11, 2022 2:09 PM
To: Georgoulias, Bethany
Cc: [e-mail]; [e-mail];
[e-mail]
Subject: [External] NPDES Permit Info Update - MarineMax East, Inc. - Wrightsville Beach
NCG190074
Attachments: 1-NPDES Owner Affiliation Change Form - SIGNED.pdf, 2-NPDES Permit Delegation of
Signature Authority Form - SIGNED.pdf
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
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Bethany -
I hope this message finds you well.
On behalf of MarineMax East, Inc. - Wrightsville Beach Facility (Permit No.: NCG190074), please find
attached herein the following:
• Completed and signed Owner Affiliation Change Form
• Completed and signed SW Permit Delegation of Signatory Authority Form
Please note that the Owner Affiliation Form has been uploaded online through the form submittal page you've
previously supplied me with. In addition, both forms shall be mailed to the addresses identified on the forms
with original signatures.
Should you have any additional questions or need any additional information, please do not hesitate to let me
know.
Thank you.
CHRIS RUHLIN
CESSWI, CPESC, CPSWQ, CPISM
Environmental Consultant
toll free: 888-762-0230 1 office: 407-720-6152
web: www.rmagreen.com I email: chrisLkn-nagreen.com

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