NCG060184_Owner-Affiliation-Change

Division or Energy, Mineral, and Land Resources FOR AGENCY USE ONLY
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Land Quality Section / Stormwater Program YCW °aiEa`,�"h""'
National Pollutant Discharge Elimination System (NPDES)
Energy. Mineral a PERMIT OWNER AFFILIATION DESIGNATION FORM
LandResources
fF+VfnCwMiH7a1, aUALf7r (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 owner hi 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 docs "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 ofCoverage
LEC3191NIMIR/
2) Facility Information:
Facility name: Qirhf,�SdG �////
Company/Owner Organization:
Facility address: 2 -OS' iv
Address
rn Al d.
...
city stale zip
To find the current legally responsible person associated with your permit, go to this website:
Ittto://deg,nc. gov/aboutl.divisionstenergv-minerii-land-resources/enerLw-mi neral-land-r)erinits/stormwater-program
and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: -Ti-n1 �i ova
First MI
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: �A•V d A. /0 Yy2SS e -*'k
First MI Last
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S W U-OWNERAFFIL-33htarch20 17

NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form
(irno Facility Name/Ownership Change)
V P e� n vires
Title
7? r
MailinIK
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City State Zip
-Mol34.530
7cicphonc E-mmil Address
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Far Number
S) Reason for this change:
A result of: 9ZEmployee or management change
❑ Inappropriate or incorrect designation before
❑ Other
If other please explain:
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATIION:
A-7--, , 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 Date
PLEASE SEND THE COMPLETED FOILM 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:
htt ://de .nc.i!ov/about/divisions/ener -mineral-land-resources/stormwater
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