NCG060102_Owner Affiliation Change_20171108

Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program 11
National Pollutant Discharge Elimination System (NPDES)
Energy, Mineral & PERMIT OWNER AFFILIATION DESIGNATION FORM
ENVIRONMENTAL Resources
QUALITY (Individual Legally Responsible for Permit)
Use this form if there been:
FOR AGENCY Umi-
Q10
Date Recei
Year
Month
of
oa
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:
Individua] Permit
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
(ar)
Certificate of Coverage
10 Ila
t_.�q�2, SPrt rtg5
Vera ue vtoppA5 t LLC.
9c Hwy all E
Address
E&iIt spnngs nIC, a7a�la
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
httD://dea.nc.eov/about/d ivisions/enerev-mineral-land-resources/enerevanineral-land-Hermits/stonnwater-nro¢ram
and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: C!!At'I C.
First Mi Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: 3
dM25 � G r-eQylei
First MI Last
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of
oa
t_.�q�2, SPrt rtg5
Vera ue vtoppA5 t LLC.
9c Hwy all E
Address
E&iIt spnngs nIC, a7a�la
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
httD://dea.nc.eov/about/d ivisions/enerev-mineral-land-resources/enerevanineral-land-Hermits/stonnwater-nro¢ram
and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: C!!At'I C.
First Mi Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: 3
dM25 � G r-eQylei
First MI Last
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NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
Ca.nAor -eec%nlll MAAttqa -
Title -
P6 Bax 55D
Mailing Address
Cctn4or dG 72 a?
city State Zip
( 91D) 673- 4W Erf/8 eAwdrJ nerd ae •coin
Telephone E-mail Address
( Rln) b73-318L
Fox Number
5) Reason for this change:
A result of: ❑ employee 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 CERTIFICATION:
I,
I, /lvwy L tattest that this application for this change in Owner Affiliation
(pers 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.
O o.i rc . — I I - 747
Signature Date
PLEASE SEND THE COMPLETED FORM TO:
Division of Energy, Mineral, an
d 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:
htto://deo.nc.�ov/abouUdivisions/enerey-mineral-land-resources/stormwater
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