NCG080720_Owner Affiliation Change_20171109

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Division of Energy, Mineral and Land Resources FOR AGENCY USE ONLY
Land Quality Section / Stormwater PermittingProgram Date Recei d
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National Pollutant Discharge Elimination System (NPDES)
PERMIT OWNER AFFILIATION DESIGNATION FORM
(Individual Legally Responsible for Permit)
if NO CHANGE in company or facility ownership or name has occurred.
if a Name Change and/or Ownership Transfer at the facility has prompted this change, do
NOT use this form. You must fill out the Name -Ownership Change Form and provide all
necessary supporting documentation instead.
1) Enter the permit number for which this change in Legally Responsible Individual ("Owner
Affiliation") applies:
Individual Permit
N I C I S
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
(or) Certificate of Coverage
N I C I G O 8 0 7 2 0
Lane Construction Wilkinson Shop
Lane Construction Corporation
8205 Wilkinson Blvd
Address
Charlotte NC 28214
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
htW://Portal.nedenr.org/web/lr/sw-permit-contacts and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Greg Davis
First MI Last
4) NEW OWNER AFFILIATION (Legally responsible for the permit):
Person legally responsible for this permit: Timothy C Gaddy
First MI Last
SW U-0 W NERAFFIL-22May2014
Plant Manager
Title
8205 Wilkinson Blvd
Mailing Address
Charlotte NC 28214
City State Zip
704 1 394-8354
Telephone E-mail Address
( 704 ) 394-5354
Fax Number
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NPDESStormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
5) Reason for this change:
A result of:
Ifotherplease explain:
What does "legally responsible person" mean?
That person is either:
❑ Employee or management change
® Inappropriate or incorrect designation before
❑ Other
• 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 that person above.
The certification below must be completed and signed by the permit
holder.
PERMITTEE CERTIFICATION:
I Timothy C. Gaddy 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.
/i/9Z-/
Signatur Date
PLEASE SEND THE COMPLETED FORM TO:
Division of Energy, Mineral and Land Resources
Stormwater Permitting Program
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
For more information or staff contacts, please visit our website:
htti)://i)or-tal.ncdenr.org/web/ir/stonnwater
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SW U -OW NERAFFIL-22May2014