NCG210147_Owner Affiliation Form_20230718

Division of Energy,Mineral, and Land Resources FOR AGENCY USE ONLY
oev.nmemoi wmomemeiomuy Date Received
Land Quality Section/Stormwater Program Yeaz Month I Day
National Pollutant Discharge Elimination System(NPDES)
PERMIT OWNER AFFILIATION DESIGNATION FORM
(Individual Legally Responsible for Permit)
Use this form if there has been:
NO ORANGE 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 C S I N I C I G;1.) *♦ 1{
2) Facility Information:
Facility name: P &1�e p(Zja
Company/Owner Organization: 72M M.►k
Facility address: 010, S'MDUtv.�Jt
Address
C.ewec' Nc-
City State Zip
To find the current legally responsible person associated with your permit,go to this website:
https:Hdey.ne.gov/sw/ 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: �7\ .rs
MI Last
4) NEW OWNER AFFILIATION(legally responsible for the permit):
Person legally responsible for this permit: p nI\
First MI Last
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Last revised M Feb 2022

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
�ant /11c,�rwa2C
Title
CQR '%M 5± SW
Mailing Address
CQPARr N_ -
City State Zip
(�aa8)5�-ka90 b cotm
Telephone E-mail Address
( )
Fax Number
5) Reason for this change: ,�
A result of: Q� Employee or management change
❑ Inappropriate or incorrect designation before
❑ Other
If other please explain:
..................................................................................................................
The certification below must be completed and signed by the permit holder.
Mote: 40 CFR 122.22(c) requires an original signature (not digital)
PERMITTEE CERTIFICATION:
1, ►llc.ck^ mom^ ,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.
AIN/CP4Q1
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(919)707-9220 or visit the website
at: http://deg.nc.gov/sw
Per NC General Statute 143-215.6B (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).
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Last revised 20 Feb 2022