NCG030085_Owner Affiliation Change_20220606

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Division of Energy, Mineral, and band Resources
Land Quality Section 1 Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
PERMIT OWNER AFFILIATION DESIGNATION FORM
(individual Legally Responsible for Permit)
Use this form if there has been:
FOR Aril»LCY USE ONLY
Ilan Rmckvd
Year morah
Da
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 ownershl>y 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" meaty?
The person is either:
■ the responsible corporate officer (fora corporation);
• the principle executi%,c officer or ranking elected official (for a municipality, state, federal or other public
agency),
• the general partner or proprietor (far a partnership or sOlc proprietorship):
■ or, the duly authorized representative of one of the above.
1) Enter the permit It Umber for ►shich this chan;;e in Legally Responsible Individual ("Owner Affiliation")
applies:
Individual Permit
Ncs 1�I 1
2) lacility Information:
Facility name:
Company/Owner Organization.
Facility address:
�r»1 Certificate of Coverage or No ExposuFe
N I C LG 1 13 16 1
1 LeiC,
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Jul"IIy -
Address f
L 1tv 5[ase Zip
To find the current lega11), responsible person ;associated ►vith your permit, go to this website:
Navigalc to the "NI'DES Industrial Program" section and run the Storill,%. ter 1'crmit
Contact Suniraar►• Report for your pemtit number.
3) OLD OWNER AFFILIATION that should he removed:
previous legally responsible individual: j ��� , ty
tri cif t.�•t
4) NEW OWNER AFFILIATION (legally responsible for the permit):
I'crsort legally responsible for this permit
�-or`�_
Firs[ 1t[ t a t
Page 1 of 2
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NPDES 5tormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility NamelOwnership Change)
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MailingAddress
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Telephone E-mail Address
Fax Numbcr
5) Reason for this change;
A result A'- Employee or management change
Inappropriate or incorrect designation before
❑ 0111cr
If o M e r please GrlJlai►i:
.............................................
The certification below must be completed and signed by the permit holder.
Note: 40 CFR'122.22(c) requires an original signature (not digital)
PERMITTEE CERTIFICATION:
1, ,J )L{rlalL( CGeeer , attest that this application for this change in Owner Affiliation
(person legal yy responsible for she permit) has been reviewed and is accurate and complete to the best of
my knowledge. 1 ondcrstand .ihat if all required parts ol'this fonn are not completed, this change may not
be processed. ,
�`, 2 _..
Signature Date
['LEASE SEND THE ORIGINAL SIGNED COPY OF THE COMPLETED
OWNER AFFILIATION CHA,NGF: FORM TO:
DFVII_R - Stonim-titer Program
Dept. of Environmcatal Quality
1612 Mail Service Center
Raleigh, North Carolina 27099.1 G 12
For more information or staff contacts, please call [phone] or visit the ►►•ebsite
at: htttt:.. dcsl.nc.gu►. sw
Per NC General Statute 143-215.613 (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 implementing this Article shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars IS IO} 000j.
1'age 2 uf2
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