NCG081008_Owner Affiliation Change_20220331

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Division of. Energy, Mineral, and Land Resources
Fnrimnmenw 1 d ��- Land Quality Section] Stormwater Program
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National Pollutant. Discharge Elimination System (NPDES)
PERMIT OWNER AFFILIATION DESIGNATION FORM
(Individual Legally Responsible for Permit)
Use this form if there has been:
rot;Arevcr use ONLY
Daly. kcccivcd
Ycar
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 ownershifv. 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. repi•esentatiw of one of the :above:.
1) Enter the .permit number for which this change in Legally. Responsible Individual ("Owner Affiliation".)
applies:
individual.Perrhit
2) Facility Information:
Facility name;
Company/owner Organization:
Facility address:
(07 ) Certificate of Coverage or No Exposure
D 18 Q O 8
SEFA Transportation
SEFA Group
9089.Old 5a4bury Road
Address
Linwood NC 2729.9
City State Zip
To find the current legally responsible person associated with your perrnit,.go to this website.-
httos.//deginc.gov/sNv/ Navigate to the "NPDES.lndustrial Program" section and run the.Stormwateir Permit
Contact. Summary Report for your permit number.
3) OLD OWNER AFFILIATION that should be rem6wd:
Previous legally responsible individual: Todd
First
4) NEW OWNER AFFILIATION (legally responsible for the. permit):
Person legally responsible for this perrDit:
Jim
First
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Widowfeld
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Lasfrevkcd20 F611022

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no :Facility Name/Ownership Change)
5) Reason far this change:
A result of:
If other please erplahr
VP SEFA Transportatlon
Title
21.9 Cedar Road
Mailing Address
Lexington SC 290.73
City State. Zip
( 803 ) .520-9000 [e-mail]
Telephone E-mail Address.
(803.) 52.0-9001.
Fax Number
❑ . mployee.or management change .
El Inappropriate or incorrect -designation before
❑ Other
1_,.,..,,..',..,,....,.'..,,... ,.l......................
The Certification below must be completed and signed by the permit holder.
Nate: 4D ,CF;R'1 :2 {c} requires an arlginal signature knot d glfia1)
PERiVnTTEE CERTIFICATION:
I, . (�VI. Vy f.. j c7�] (�l t; [� , attest that.this application for thiss 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 6ange .may not
be processed.
�"\-'kj
Signature.
3125/2022
Date
PLEASE SEND THE ORIGINAL SIGNED COPY OF THE COMPLETED
OWNER AFFILIATION'CHANT GE F'ORNI TO.:
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 276.994612
For more information or staff:contacts,.please .call (9.19) 707-9220 or visit the website
at: htt :Ildc .nc. ovlsw
Per NC General Statute 1437215.613 (i), any person who knowingly makes -any false statement, representation, or
certification in any application, record, report, plan, or -.other document Filed or required to be maintained under this
Article or a rule implernenting this Article .... shall be.guilty of a Class :2 misdemeanor which. may include a fine. not to
exceed ten thousand. dollars ($:1.0,000).
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Last revised 20 F6 2622