NCG120017_Owner Affiliation Form_20221208

DocuSign Envelope ID: ED4F4FE8-DD90-4B9E-97E1-FF27BF6B186D
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Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
Energy. Minerals PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resources
E.an�nev,noonu,. (Individual Legally Responsible for Permit)
Use this form if there has been:
FOR AGENCY USE ONLY
Dale Received
Year
Month
Da
RECEIVED
DEMLR-Stormwater
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:
• 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 12 0 0 1 7
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
Cumberland Cc - Ann St
Cumberland Co
698 Ann St
Address
Fayetteville NC 28301
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
https://deg.ne. gov/about/divisions/energy-mineral-I and-resources/energy-mineral-land-perm its/npdes-industri al-
rp ogram and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Jerod Roberts
First MI
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: Amanda Bader
First MI Last
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DocuSign Envelope ID: ED4F4FE8-DD90-4B9E-97E1-FF27BF6B186D
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:
Director Solid Waste Management Department
Title
698 Ann St
Mailing Address
Fayetteville NC 28301
City State Zip
(910 ) 438-4041 [e-mail]
Telephone E-mail Address
Fax Number
0 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, Amanda Bader , 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.
Docuftned by:
QwtatL4 bojv 12/1/2022
36000FB439664BE... Signature - Hate
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: http://deg.nc.gov/about/divisions/energy-mineral-land-resources/stormwater
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