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Home My WebLink AboutNCG120095_Owner Affiliation Change Form_20171030Energy, Mineral & Land Resources ENVIRONMF,NTAL QUALITY Division of Energy, Mineral, and Land Resources Land Quality Section / Stormwater Program National Pollutant Discharge Elimination System (NPDES) PERMIT OWNER AFFILIATION DESIGNATION FORM (Individual Legally Responsible for Permit) Use this form if there has been: FOR AGENCY USE ONLY Date Received Year Month Day r ' +� • Vffj I CGO I I• 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 ranldng 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 N I C I S I 1�] 2) Facility Information: (or) Certificate of Coverage IN I G I G Facility name: 1@(f f"�, ) Company/Owner Organization: 1 Facility address: ( € Int City � State Zip To find the current legally responsible person associated with your permit, go to this website: httpa/deg.nc. �ov�aboutldivisiolislenergy-mineral-land-resources/energy-mineral-land-permits/stormwater-proal•am and run the Permit Contact Summary Report. 3) OLD OWNER AFFILIATION that should be removed: Previous legally responsible individual: First 4) NEW OWNER AFFILIATION (legally responsible for the permit): ►iTil Last Person legally responsible for this permit: k First I MI Last Page 1 of 2 S WU-OWNERAFFIL-23March2017 NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form (if no Facility Name/Ownership Change) 5) Reason for this change: A result of: If other' please explain: City Telephone �) IT Fax Number State Zip E-mail Address Employee or management change ❑ Inappropriate or incorrect designation before ❑ Other ............................................................................................................... The certification below must be completed and signed by the permit holder. PERMITTEE CERTIFICATION: - °�' .�. ,attest that this application for this change in Owner Affiliation legally responsible or the permit) has been reviewed and is accurate and complete to the best of my lge. I understand that if all required parts of this form are not completed, this change may not be ,processed. Division of Energy, Mineral, and Land Resources Stormwater Program 1612 Mail Service Center Raleigh, North Carolina 276994612 Date For more information or staff contacts, please call (919) 707-9220 or visit the website at; http'!/deq nc fav/aboutldivisionslenel•Qy-mineral-land-resoul•ces/storinwater Page 2 of 2 SW U-OWNERAFFIL-23Mai2017 NC Division of Energy, Mineral and Land Resources NPDES Stormwater Permit Contacts Summary NC D1;114Ln has the following contact information in our Permit Database for vour permit as of 10/24/2017. Permit Number: NCG120095 Permit Type: Landfill Stormwater Discharge COC Facility Name: Facility Addressl: Facility Address2: City, State & Zip: Old salisbury Road Landfill 3336 Old Salisbury Rd Winston Salem NC 27127 Owner Information Details: Owner Name: Winston-Salem/Forsyth County Utilities Commission Owner Type: Government - Municipal Owner Type Group: Organization Owner Affiliation: Rvn�argroue � ''{� t�(� � �� % Title: Director of Utilities Addressl: PO Box 2511 p Address2: City , State Work Phone: 336-7-47-7312' `( ` (Y : Email Address: ('OKA t A4E_C f� ��1 0(4-`4o Cu C� Contact Name Title '' Address [avid -tea n lt`��02_l:�F-irst�t 'nstan-Salem,-NC— Fax: Phone Fax , �fU C-eurtney-Driver Barry _Shearin UtilitiesSup>' P¢..Box-251, Winston-Salem, NC 2, 1 -100 -@-St 21; Winston-Salem, " 336=747-7315court+�eyd@eityofws NC -27192 � 7-107-9998 „orq-. William S Barfoot PO -Box -2511, Winston-Salem, NC 336=727-2507 336-'7227-8431 NC 27-107=9998-. - 27197-9998— Edward --Gibson--, PO-8ox2511,Winston.Salem, NC 336-727=8000 3367727-8432 NC 27107-9998-- 27f67=9998 -- Michael--Goliber PO-Bex-251-1-r Winston-Salem, NC 336-7-27-8418 336-727-8432 NC ,27107-9998` Ron-Nargrove PO Box 2511 Winston Salem, NC 33&7-47n7312 �71B7y9998 Contact Name Title �i�EC3� r Address 3336 Old Salisbury Rd, Winston Salem, Phone Fax Email � - � X59 3 8 .edwart 1/24/2017 � Page 1 7-107-9998 Andrea-Keywr PO -Box -25Y1, Winston Salem, NC 27197-9998— Philip --Hauser PO Box -2511, Winston Salem, NC 27f67=9998 -- Torrr-Griffin} 1?Q Box 2511, Winston Salem, NC Contact Name Title �i�EC3� r Address 3336 Old Salisbury Rd, Winston Salem, Phone Fax Email � - � X59 3 8 .edwart 1/24/2017 � Page 1 NC Division of Energy, Mineral and Land Resources NPDES Stormwater Permit Contacts Summary NC DEMLR has the followinE contact information in our Permit Database for your permit as of 10/24/2017. Permit Contact Person(s) Contact Name Title Address Phone Fax Email Contact Name Edward Gibson e 10/24/2017 Title Address t ,� 33 aynes l JLkRd, Winston Salem, Phone Fax Email 3 656q659� 336"7749 t8 edwardg@cityofws.or ' �V 4-Sb4 9 Page 2 NC Division of Energy, Mineral and Land Resources NPDES Stormwater Permit Contacts Summary NC DEMLR has the following contact information in our Permit Database for your permit as of 10/24/2017, Permit Number: NCG120034 Permit Type: Landfill Stormwater Discharge COC Facility Name: Winston Salem - Hanes Mill Rd Sanitary Landfill Facility Addressl: 325 Hanes Mill Rd Facility Addressl: City, State &Zip: Winston Salem, NC 27105 Owner Information Details: Owner Name: City of Winston-Salem Owner Type: Government - Municipal Owner Type Group: Organization Owner Affiliation: ✓ Addressl: Addressl: City, State & Zip: Work Phone: Email Address: Contact Name Contact Name Edward Gibson Courtney Driver PO Box 2511 Winston Salem, NC 27102-2511 336-747-7315 courtneyd(a)cityofws.org Title iC X799 Griffith Rd, inston Salem, NC _,. 27103 -6417 -- 2800 -River Rdg Rd,-Pfafftowrf, NC Address PO Box 2511, Winston Salem, NC Contact Name Title Address Edward Gibson PO Box 2511, City of Winston-Salem N P, Winston Salem, NC Contact Name Title Address Edward Gibson PO Box 2511, Winston Salem, NC Fax: Phone Fax 336-397-7b25#_ 336:,65�.�320 8LK 336 945-1179• 336=94&25;W Phone Phone 3�6=b62��F9Q3~ 2 -.7 " I Fax 336=661=4905 Fax 336-727-8432 Email -� billb@citgofws:org m Email edwardg@cityofws.o Email C; Email t� 10J24/2017 Page 1