NCG060174_Owner Affiliation Change_20171103

Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
Ener yr. tLirnrnr! PERMIT OWNER AFFILIATION DESIGNATION FORM
Lwt;NrrU At [. rrs (Individual Legally Responsible for Permit)
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Use this form if there has been:
I`OR AGENCY USE ONLY
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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
N C 5 N C G 0 (a O l? t-(
2) Facility Information:
Facility name: Pt jqr(-MS er+CIQ.. L-oreorcc am
Company/Owner Organization: Self1 t I?lcnt
Facility address: Lk 84 ?&mmarman
Address
SaArcl hk— OL7336
City state 'Lip
To find the current legally responsible person associated with your permit, go to this website:
http:l/detl.nc.gc�v/abotllIlli visionsrenrrgy_mi[terul-Ihttd-_reso�lrceslenerev-miner,[ I -Ionil -pt rm it515tornn+ater-prngrt�m
and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be r moved:
Previous legally responsible individual: Im
First MI I, I
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: f,)OU4-� A • �t�nsen
First MI Last
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NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
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Mailin Address
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Telephone 1: -mail Addretis
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Fax Number
5) Reason for this change:
A result of [IEmployce or management change
❑ Inappropriate or incorrect designation before
❑ Other
If ocher please expla/ .
..................................................................................................................
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
I, zd .A. , 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
processed.
Signature
h Z 3 /1 7
Date
PLEASE SEND THE COMPLETED FORM TO:
Division of Energy, Mineral, and Land Resources
Stormwater Program
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
For more information or staff contacts, please call [phone] or visit the website at:
lilt :lido .nc.;-,ovr'abouti 'v' ' nOencr, mineral -land -re ou a .storinwater
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