NCG030571_Owner Affiliation Change_20171025

Division of Energy, Mineral, and Land Resources FORAGENCYUSHONLY
pato Recemd
Land Quality Section / Stormwater Program JIUMNUMN Day
N
National Pollutant Discharge Elimination System (NPDES)
kneqjy, Mitteral $4 PERMIT OWNER AFFILIATIONDESIGNATION !
taiidResourves
FHVJ110%1sNTAt,flVAUPV (individual Legally Responsible for Permit)
Use this form if there has been:
fac€I€ty+9wnersh€p or fac€I€ty name, but the €nd€v€dtla€
who is legally responsible for the permit has changed.
!t the name of the facility has changed, or iP 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 farm with all required documentation.
What does "legally respmisible individual" mean?
The person is either:
• the responsible corporate officer (for a corporation);
• the principle executive officer or ranking elected official (for a mutucipality, state, federal or other public
agency);
• the general partner or proprietor (for a partnership or sole proprietorship);
• or, the duty authorized representative of one of the above.
1) Enter thepermitmuuberforwhichthischangeinLegallyResponsibleIndividual("OwnerAffiliation")
applies:
Individual Permit
Z) Facility Information:
(or)
Certificate of Coverage
Facility name:
Company/Owner Orgarilzation: (�/ttl2 �uGw�v(g, e 1
Facility address: is oCJ �,4 i7o� i
Address
Jd4rrhwog A/XL vlet?10
City, stste Zip
To end the current legally responsible person as
sociated with your permit, go to this website:
httn://deg.nc, govtabout/divisions/enemy-mineral-landaesources/eneraymineral••land••permits/stormwater-progt �m
and ran the Permit Contact Summary Report.
3) OLA OWNER AFFILIATION that should he removed:
Previous legally responsible individual: t>6yA
c1
Fvat MI last
A) iV�W OWNER AFFILIATION (legally responsible for the
permit):
Person legally responsible forthispermit: �(^ rIS W. ' 1 QS[�il
First W Last �
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S W U-OWNRRAPFIG23Niarah2017

NPDES Stormwater Permit OWNER APFILATION DESIGNATION Porta
(if no Facility Name/Ownership Change)
[iCrJL•RA4 MAa
Tifla
3'O•b0 "W y 'A E
Mailing Address
MoaRoF nl(� z$+tz
city state zit
o''i)442-•.z4 d.s.-,rN os�cy@ 4ss0.w�\oy.
Telephone E-mail Address
FaxNwnbec
5) Reason for' this change:
A result of: Employee or management chango
❑ Inappropriate or incorrect desigmationbefore
❑ Other
If other plense explain:
The certification below must be completed and signed by the permit holder:
kFRMITTEE
I, nn
1R15 n/)os8� attestthatthisapplicationforthischaogelnOwnerA£fellation
(person legally responsible for the permit) has beenreviewed and is accurate and complete to the best of my
knowledge. I understand that if all required profs of this form are not completed, this change may not be
processed.
! d /zs%, 7
Si nature Date
PLEASI+ SEND T.IIF, COMPLI+TED FORM TO:
Division of Energy, Mineral, and Land Resources
Stormwater Program
1612 Mail Service Center
Raleigh, North Carolina 276994612
Por more information or staff contacts, please call [phone] or visit the website at:
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