NCG120098_Owner Affiliation Form_20230628

Division of Energy,Mineral,and Land Resources FOR AGENCY USE ONLY
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Land Quality Section/Stormwater Program { Y0 r I lhu
National Pollutant Discharge Elimination System(NPDES)
PERMIT OWNER AFFILIATION DESIGNATION FORM
Lai-ty ',_rzoRmv1
wry , ;ea�rawwrr (individual Legally Responsible for Permit)
Use this form if there has been:
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 owneershlo of the facility has changed,
do HOT 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 AflWation")
applies:
Individual Permit (or) Certificate of Coverage or No Exposure
N ICI S I I I I I I I I N I C I G 1112 10 10 19 18
2) Facility Information:
Facility name: Evergreen Packaging Landflll
Company/Owner Organization: Blue Ridge Paper Producle LLC,a wholVawned aabaldlary of Pactiv Evergreen Ina
Facility address: 1155 incinerator Road
Address
Canton _ NC 28716
City State Zip
To find the current legally responsible person associated with your permit,go to this website:
hops://deq.nc.zov/abgil divi$io ineW4and-msources/eneror mineral-land-yermiWn dusft4al-
prograrn and run the Permit-Contact Summary Report. —
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: John A McCarthy
First M1 Last
4) NEW OWNER AFFILIATION(legally responsible for the permit):
Person legally responsible for this permit: James J Clary
First MI Last
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NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name(Ownership Change)
General Manager-Canton Mill
Title
175 Main Street
Mailing Address
Canton NC 28716 _
City state Zip
828 } 492-6189 [e-mail]
Telephone E-mail Address
Fox Number
5) Reston for this change:
A result of: © Employee or management change
0 Inappropriate or incorrect designation before
❑ Other
If other please explain:
..................................................................................................................
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
L James Clary .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
•used.
'.' _ :a
gnatare Date
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(919)707-9220 or visit the website
at: -itip://dw.nc.gov/about/divisions/e- -, mineral-land-resources/stormwater
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