NCG080991_Owner Affiliation Change_20220331

Division of Energy, Mineral, and Land Resources
Land Quality Section /. Stormwater Program
oepsmnert M Ertrbpnmmtl R:ialitr. .
National.Pollittant Discharge Elimination System (NP..D.ES)
PERMIT OWNER AFFILIATION DESIGNATION FORM
(individual Legally Responsible for Permit)
Use this form if there has been:
FOR AGENCY USE:ONLY
Date Receiwd
Year
�Ioptls
i7ay
ND 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 personis 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 (Fora partnership or sole proprietorship);
■ or, the. duly authorized representative of one of the..above:
I). Enter the permit number for which this change in Legally Responsible .Individual ("Owner Affiliation'.
applies:
Individual Permit (or) Certificate of Coverage or No Exposure
2) Facility. Information:
Facility name: SEFA Transportation
Company/Owner Organization: SEFA Trarisportation, Inc
Facility addrew 4293 and 4309.Racing Drive
Address
Denver NC 28037
City. State Zip
To find the current legally responsible person associated with .your permit,:go to this website:
haps:lldeg.ne.govlswl Navigate .to the PDES Industrial Program" section and run the: Stormwater Permit
Contact Summary Report for your permit number.
3) OLD OWNER AFFILIATION that -should be removed:
Previous legally responsible individual; Todd C Wilson.
First M1 Last
4) NEW OWNER.AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: Jinn Wldowfield
First N[I East
Page 1 of 2
East 6cyNed 2.0 Feb 202Z

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:
VP SEFA Transportation
Title
219 Cedar Road.
Mailing Address
Lexington. _ SC 29073
City Statc: Zip
803 ) 520-9000: [e-mail]
Telephone E-mail Address
.(80:3 ) 520-900I
Fax ?number
❑ Employee or management Change
❑ Inappropriate or1ricorrect designation before
❑. Other
,,,.. ,,..,I,., , _ . . i ...................... .....:.j,...,
The certification below must be completed and signed by the. permit holder.
Note: 417 CFR 122 22(c) require- an. original signature (not 'digital]
PERMITTEE CERTIFICATION:
1, .,X(O UJII) Lr-4 F, a_b , attest that this application Fot 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, thischange may not
N processed,
Signature
3/25/2022
.Date
PLEASE SEND THE. ORIGINAL SIGNED. COPY OF THE COMPLETED
OWNER AFFILIATION CHANGE FORM TO::
DEMLR - Stonziwater Program
Dept. -of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina27699-16.12
For more information or staff contacts,.please call [phone] or visit the mebsite
at: h :/lde .nc.,ovlsw
Per NC General Statute 143--215.613 (i), any person who knowingly makes any falsestatement,.. representation, or
certification. in any application, record, report, plan, or other document liled.or required:to be maintained un..der:this
Article. or a ruleimplementing this Article:... shall be guilty of a Class:.2 misdemeanor which may include:a fine not to
exceed ten thousand. dollars. ($10,000).
Page of
Last revised 20 Feb 2022