NCG060336_Owner Affiliation Change_20231102

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Q Division of Energy, Mineral,and Land Resources FOR AGENCY USE ONLY
Date Received
rielinn et menww.rx� /� Land Quality Section /Stormwater Program Year Month Day
V National Pollutant Discharge Elimination System (NNUI:S)
PERMIT OWNER AFFILIATION DESIGNATION FORM
(Individual Legally Responsible for Permit) 11ij /
Use this form if there has been: �J
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) F,uler 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 N C G O (0 0 3 3
2) Facility Information:
Facility name: i V fr -1/
Company/Owner Organization: rcrg rvy, /"�,
Facility address: oI --gn' 0_C3OS 438)
Cl h
A ress
� MG V321)
City Slate Zip
To find the current legally responsible person associated with your permit,go to this website:
https:/ldey.ncgov/sw:' Navigate to the "NPDES Industrial Program" section and run the Stormwater Permit
Contact Summary Report for your permit number.
3) OLI)OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Willa - — ! Presqvge—
First MI Last
4) NEW OWNER AFFILIATION(legally responsible for the permit):
Person legally responsible for this permit: ---1;�'i/, 2 4,--/ .6.
First MI Last
Page I of 2
List revised 20 Feb 1n22

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
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City State Zip r
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Fax Number
5) Reason for(his change:
9 .mploycc or management change
A result of: ❑ Inappropriate or incorrect designation before
❑ Other
If other please. explain:
The certification below must be completed and signed by the permit holder.
Note: 40 CER 122.22(c) requires an original signature (not digital)
PERtMITTEE CERD FICATION:
1, L.h I. tf ,attest that this application for this change in Owner Affiliation
(person legally responsib )r 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.
. 01--/ �,GO /O 012.013
Signatur Date
PLEASE SEND TILE ORIGINAL SIGNET)COPY OF THE CO31PLETED
OWNER AFFILIATION CHANGE FORM TO:
DEML12-Stormwater Program
Dept.of Environmental Quality
16(2 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://dcq.ne.gov/sw
Per NC General Statute Id3-215.613(i),any person who knowingly makes any false statement. representation.or
certification in any application, record,report, plan, or other document Tiled or required to be maintained under this
Article or a rule implementing this Article .. .shall be guilty of a Class 2 misdemeanor tvhich may include a fine not to
exceed ten thousand dollars($10,000).
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Last r,viseJ 20 Feb 2022