NCG060182_Owner Affiliation Change_20171103

Division of Energy, Mineral, and Land Resources FOR AGENCY GSE ONLY
Rewi
Land Quality Section / Stormwater Program Y. °glom Q1C. o,
National Pollutant Discharge Elimination System (NPDES)
Energy. MineroU PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resources
INVINOu,MUCNAM (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 awnershio of the facility has changed,
do NOT use this fonn. 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
ON1@11MI I I I I IN106-ex I 0 1610 1 MMI
2) Facility Information:
Facility name: 4rtv►.S IPtiLC Jl tkyro.:t–
Company/Owner
Organization;
Facility address: 510 LWkil --Blvd
-� Address
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
hti aide .nc. ov/about/divisions/ener -mineral-land-resotirces/ener v -mineral -land- rmits/Stormwater-pMg[gm
and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Ln—
First twtl Law
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: ' /id A-. —7;t✓lt Aa.J,
First MI last
Page I ort
S WU-OWNERAFF1L-23N6rrtr2D 17

NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form
or no Facility Nnme/Ownership Change)
vvklera j zr1V;M1na1Ak
Title
h[niling Ads Q
City State Zip
%-?--5930 '--F->
r rphonc E-mail Address
�) NIA
Pae N umber
5) Reason for this change:
A result of: ID/Employee or management change
❑ Inappropriate or incorrect designation before
❑ Other
If ocher please explain:
...................................................................................................................
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
1,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.
A
Signature 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:
hit // a .nc. ov/aboutldivisionslen r -mineral-!an -r ourceslstartnwnter
Pale 2 of 3
s w u -v w art: R AF F a-33 n6 0017