NCG020928_Owner Affiliation Change_20230804

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Division of Energy, Mineral, and Land Resources FOR AGENCY USE ONLY
entoEnvironmental Land Quality Section / Stormwater ProgramDate Received
Department of 0uality � y g Year Month Day
National Pollutant Discharge Elimination System (NPDES)
PERMIT OWNER AFFILIATION DESIGNATION FORM
(Individual Legally Responsible for Permit)
Use this form if there has been:
Cr.Ai••CAE in facility ownership facilityname, but the i i i 5i
w is legally responsible for the permit h .s 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 (oi) Certificate of Coverage or No Exposure
N C S O 0 0 9 a ? N C G
2) Facility Information:
Facility name: kOu,, 1 a..r1‘6. I
Company/Owner Organization: 1-.05 u,i qn k 1,C
Facility address: ?DD lock o Epecn
Addre s
_ Q73(0O
Oity State Zip
To find the current legally responsible person associated with your permit, go to this website:
https://deq.nc.gov/sw/ Navigate to the "NPDES Industrial Program" section and run the Stormwater Permit
Contact Summary Report for your permit number.
al
3) OLD OWNER AFFILIATION that should be removed:(1eJ 1�5 I'S°n �C`s ye( P
oaf of30)n;g61-7 °n 1
,
Previous legally responsible individual: f ,�
First MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: • 1/ i L'Tl
First M1 Last
Page 1 of 2
Last revised 20 Feb 2022

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
Vt�ee Orlr
Title
2667
Mailing Address
0L a�i\Q✓'en t\ C 2? ! Z�
City State Zip
(95-0 43--e?Oga ✓'icv p c,f'M Sf(ore ..reprpoicA.
Telephone E-mail Address e45,0\
( asa) 911-Z 33 0 8'
Fax Number
5) Reason for this change:
❑ Employee or management change
A result of: ❑ Inappropriate or incorrect designation before
[S, Other
I/'other please explain: Do n t CO 1,3t oa7" person e yen is
The certification below must be completed and signed by the permit holder.
Note: 40 CFR22 ) requires an original signature (not igi
PERMITTEE CERTIFICATION:
M51-ro , 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. 1 understand that if all required parts of this form are not completed, this change may not
be processe .
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://deq.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).
Page 2 of 2
Last revised 20 Feb 2022