NCG080299 affiliation form

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Division of Energy, Mineral and Land Resources rOR AGJINCY USE ONLY
Date Received
Land Quality Section 1 Storrnwater Permitting Program Year I KFmtn I Day
National Pollutant Discharge Elimination System (NPDES)
PERMIT OWNER AFFILIATION DESIGNATION FORM
(individual Legally Responsible for Permit)
it NO CHANGEin compapy or facility ownership or name has occurred.
if a Nawne Chane andibr Ownership Transfer at the tacifity hayc ptemthis change, do
NOT use this fon cif, YOU MUstf 'ill out the Me�Owner i � a� FoKm and p roe dj all
e esSary Supporting docualeintation i Vto r
I) Enter the permit number for which this change in Legally Responsible Individual ("Owner
Affiliation") applies:
Individual Pcum't (or) Certificate of Coverage
N C' 6 0 1 8 1 0 1 2 9 9
2) Facility Information:
Facility name: Holland Transfer Company
CompanylONvncr Organization: Holland Transfer Company
Facility address: 2088 Salisbury Hwy
Address
Statesville, NC 28677
city State Zip
To find the current legally responsible person associated with your permit, go to this website:
htt `;tort l.rzcdet r.or c _1 -1r..s -€�vrr t-� ontacts and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual! Gene Kaiser
First Ml Last
4) NEW OWNER AFFILIATION (Legally responsible for the permit):
Person legally responsible for this permit_ Dawn Foxy
First Ml Last
Vice President / GM
Title
2227 Salisbury Hwy
Mailing Address
Statesville, NC 28677
City State Zip
( 704 978-3286 [e-mail]
Telephone E-mail Address
704 ) 878-6393
Fax Number
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SVVU-OVVNE RAFFI L-22 May2014

NPDESStormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
S) Reason for this change:
A result of: [J Employee or management change
❑ Inappropriate or incorrect designation before
❑ Other
If other please explain:
What does "legally responsible person" mean's
That person is eithe�A :
a the responsible corporate officer (for a corporation
4 the principle executive officer or raiiking elected official (for a intmicip lith,,
State, federal, or other public. agency -
m
m the general paftner or proprietor (for a partnership or sole proprietorship):
4 or the duly autho6zb ti representative of that person above.
The certification below must be completed and signed by the permit
holder.
PERMITTEE CERTIFICATION:
I. Dawn Foxx attest that i application for this change in Owner Affiliation
(person legally responsible for the permit) has n reN ewed and is accurate and complete to the best of my
knowledge. 1 understand that if all requiredp of this form are not completed, this change may not be
processed. /1 f ,
b r - x) CT -8
Signature
11.7.17
PLEASE SEND THE COMPLETED FORM TO:
Division of Energy, Mincral and Land Resources
Stormwater Permitting Program
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
Date
For more information or staff contacts, please visit our website:
ht :// or al_nedenr.or Nvebrlr/stornhvN ater
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SM-OWNERAFF! L-22May2014