NCG240027_Owner Affiliation Change_20230214

ODE���1/(f Division of Energy, Mineral, and Land Resources
NUR:H CARLYJNA � ,
�,& 6_. � Land Quality Section / 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 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:
• 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
N I C S
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
(or) Certificate of Coverage or No Exposure
N I C IG 2 4 0 0 2 7
City of Laurinburg Type 1 Solid Waste Compost Facility
City of Laurinburg
600 Hall Street
Address
Laurinburg NC 28352
City State zip
To find the current legally responsible person associated with your permit, go to this website:
Navigate to the "NPDES 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: Angie
First
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: Charles
Foster
NH Last
D Nichols III
MI Last
Page 1 of 2
Last revised 20 Feb 2022

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:
City Manager
Title
PO Box 249
Mailing Address
Laurinburg NC 28353
City State Zip
(910 ) 276-8324 [e-mail]
Telephone E-mail Address
Fax Number
❑ Employee or management change
❑ Inappropriate or incorrect designation before
❑ Other
...................................................................................................................
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, Charles D. Nichols III , 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
�-rz-23
Signature Date
PLEASE SEND THE ORIGINAL SIGNED COPY OF THE COMPLETED
OWNER AFFILIATION CHANGE 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,'§
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 ($10,000).
Page 2 of 2
Last revised 20 Feb 2022

1/12/23, 3:23 PM
Submission Completed
DEQ sIx111P ES Stormwate.• Permit Contact Update
Request
NPDES Permit Enter your NPDES stormwater permit number or Certificate of Coverage (COC) number.
Number` NCG240027
Begins with NCS, NCG, or NCGNE (no exposure)
Facility Name * City of Laurinburg Type 1 Solid Waste Compost Facility
(Used to verify permit number)
Check permit contact information for your permit by running a Stormwater Permit Summary Report.
Guidance for COC holders: Do not enter the General Permit number with all 0's (for example, NCG030000) but
instead your Certificate of Coverge (COC) number.
Check all that Owner Affiliation (Legally Responsible Individual) Update
apply: * Permit Ownership Transfer or Facility Name Change
Delegation of Signature Authority (DOSA)
Permit Contact Update
Billing Contact Update
Facility Contact Update
Other Contact Update
Owner Affiliation (Legally Responsible Individual) Change
Upload a copy of the completed and signed Permit Owner Affiliation Designation Form below. We can begin making
updates with this submittal, but please note that you must mail in the original signed copy to our office, in
accordance with requirements in 40 CFR 122.22.
Staff may contact you to confirm the requested change if this Owner is also associated with other permits in our
system. Changes to Owner Affiliation affect all permits tied to that Owner.
Owner Affiliation Please upload the signed "Permit Owner Affiliation Designation Form"
Change Form Permit Owner Designation Form. df
Upload * g p 524.54K6
NPDES SW eDMR Owner Verification. pdf 51.04KB
pdf only
Submitter's Name * Please enter your FIRST and LAST name
Angie Foster
hftps://edocs.deq.nc.gov/Forms/Form/Submit
1 /2

1/12/23, 3:23 PM
Submission Completed
Phone Number*
Email Address *
Please enter your phone number
910-276-2364
Any format is fine.
Please enter a valid e-mail address
[e-mail]
A confirmation of submission will be e-mailed to this address.
* By checking the box and signing below, I certify that:
have given true, accurate, and complete information on this form;
agree that submission of this form is a "transaction" subject to Chapter 66, Article 40 of the NC General Statutes (the
"Uniform Electronic Transactions Act");
agree to conduct this transaction by electronic means pursuant to Chapter 66, Article 40 of the NC General Statutes
(the "Uniform Electronic Transactions Act');
understand that an electronic signature has the same legal effect and can be enforced in the same way as a written
signature (except for any uploaded Owner Affiliation Change or Delegation of Signature of Authority forms, which
also must be mailed in with original signature); AND
intend to electronically sign and submit this Permit Contact Update Request form.
Signature*
Date
1 /12/2023
Questions? Contact [e-mail].
https://edocs.deq.ne.gov/Forms/Form/Submit 212