NCG210192_Owner Affliation_20220607

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Division of Energy, Mineral, and Land Resources FOR AGENCY USE ONLY
Date Received
Land Quality Section /Stormwater Program N
W1�
National Pollutant Discharge Elimination System (NPDES) Received
Energy.Mineral& PERMIT OWNER AFFILIATION DESIGNATION FORM JUN 0 7 2022
Land Resources
ENVIRONMENTAL QUALITY (Individual Legally Responsible for Permit)
Winston-S 'Iorrt
R^gional Office
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 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 2 1 0 1 9 2
2) Facility Information:
Facility name: PalletOne-Mocksville
Company/Owner Organization: PalletOne of NC, Inc.
Facility address: 165 Turkeyfoot Road
Address
Mocksville NC 27028
City State Zip
To find the current legally responsible person associated with your permit,go to this website:
https://deq.nc.gov/about/divisions/energy-mineral-land-resources/energy-mineral-land-permits/npdes-industrial-
program and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Larry Draughn
First MI Last
4) NEW OWNER AFFILIATION(legally responsible for the permit):
Person legally responsible for this permit: Brian Dyson
First MI Last
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NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
Regional Manager
Title
165 Turkey Foot Road
Mailing Address
Mocksville NC 27028
City State Zip
(919 ) 353-0336 [e-mail]
Telephone E-mail Address
( )
Fax Number
5) Reason for this change:
O Employee 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.
PERMITTEE CERTIFICATION:
I, Brian Dyson , 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.
7; /O-Ao -al
Signature Date
PLEASE SEND THE COMPLETED 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://deq.nc.gov/about/divisions/energy-mineral-land-resources/stormwater
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