NCG030047_Owner Affiliation Change_20240124

V
‘f,) Division of Energy, Mineral, and Land Resources FOR AGENCY USE ONLY
' � /��/ Land QualitySection/Stormwater Program Date Received
t���;�t i r _ ,����:r�F 4u�>i� V 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:
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) 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 N C G 0 3 0 0 4 7
2) Facility Information:
Facility name: Raven Antenna Systems (dba)Global Skyware
Company/Owner Organization: Global Invacom Limited
Facility address: 1315 Outlet Center Drive
Address
Smithfield NC 27577
City 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.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Robert Scott
First MI Last
4) NEW OWNER AFFILIATION(legally responsible for the permit):
Person legally responsible for this permit: Michael Jackson
First MI Last
Page 1 of 2
Last revised 20 Feb 2022

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NPDES Stormweter Petmlt OWNER AFFILIATION DESIGNATION
Form(if nn Facility Nanit!On nership Change)
VP Seles for the Amarlrjs
Ti;tr
1315 Outlet C©ntsr Drive _
ltmilira hddrm
Smithfield NC 27577
rile Sra Zii
019 )BB9•1177 michaelOokson@plobalsityworE
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Fu Nua1e'
5) Reason for this chungc:
A result ef: El Eriv1.7•ce r_management cbiui e
(� hwirorriate orineemct eV—doe/ion bciac
p rater
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The certification below must be completed and signed by the permit holder.
Note: 40 CFR 122,22•(c•} requires an original signature(not digital)
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PERMI1TEE CERTIFICATION.
I. f•tchaet Jackson ,attest that this application for this change in Owner Affiliation
tpc xn lccal'n-'tc por i ik ft tFe permit)has bict rvrirxed and is accurate and cixi!ptetr to the be,s;of
my Ironsitap. I wtdi[ll2,n,t th t it all required parts o:this fbni arc Dot complain!,this chanpc may not
Signatuir Date
PI.F.ASF SEND THE ORIC:I,NA.L SIGNED COPY OF THE COMPLETED
OWNER AFFILIATION CHANCE FORM TO:
DENILR.•Stc rmt--atcr Program
pipe.tit-Environmental()lathy
1612 Mall Scri ice Center
Raleigh,North Carolina 27609-102
Far near in mneC•VVn nr staff contacts,please call(919)71(1-0220 or visit the We site
at:l /deli.re.:,vmvlsw
Pert C General Statute 143-215.611 fi),any person who krtriwiittly mates any fain statement.r p:est-.,t tier,or
ernification in any application,record,report,plan,or other dueuraent tiled or required to be maintained order this
Art:cic or a rule imphincttting this Article..•shall be guilty of a Class 2 misderne=nor which may include a fine not to
cxcecd tcn thousand dollars(S10,000).
Page 2 of?
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Lag r word 11i Ect,1021