NCS000105_Owner Affilition Form_20230628

Division of Energy,Mineral,and Land Resources Fos aaE CY use ONLY
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Land Quality Section 1 Stormwater Program Year Month n°�`M
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National Pollutant Discharge Elimination System(NPDES)
PERMIT OWNER AFFILIATION DESIGNATION FORM
laarsrot frr�ar (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 ownership of the facility has changed,
do NOT use this form.Instead,you must flit 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 AtYlhation")
applies: .
Individual Permit (or) Certificate of Coverage or No Exposure
N I C S 0 lo lo 11 1 N I C G
2) Facility Information:
Facility name: Canton MITI
Company/Owner Organization: Blue Ridge Paper Products LLC dbe Evergreen Packaging
Facility address: 175 Main Street
Address
Canton NC 28716
city stare zip
To find the current legally responsible person associated with your permit,go to this website:
hit s:l .n _ vlabout/divisi n ene3 -mineral-land-resourceslener r-mineral-land-Vermita e -industrial-
program and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: John A McCarthy
First MI Last
4) NEW OWNER AFFII.IATION(legally responsible for the permit):
Person legally responsible for this permit: James J Clary
First MI Last
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3wU-OwNERAFPn.4No 2019

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/OwnersMp Change)
General Manager-Canton Mill
Title
175 Maln Street
Mailing Address
Canton NC 28716
City State Zip
828 E 492-6189 James.claryCpactivevergreen.com
Telephone E-mail Address
S t
Fax Number
5) Reason for this change:
0 Employee or management change
A result of: 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:
I, 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
proaQw*ed.
4�g'
Si_. witure Date
PLEASE SEND THE COMPLETED FORM TO:
DEN LR-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: hit ://d ...nc. -ov/about/divisions/energv-mineral-land-resources/stormwater
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