NCG120086_Owner Affiliation Change_20171114

Division of Energy, Mineral, and Land Resources FOR AGENCY USE ONLY
Mate
Land Quality Section / Stormwater Program I Year Month Day
National Pollutant Discharge Elimination System (NPDES)
Energy, Mineral & PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resources
ENVIRONMENTAL QUALITY (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 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:
Individual Permit
N C I S
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
(or) Certificate of Coverage
N I C I G 1 1 1 2 1 0 1 0 1 8 6
Cabarrus County C&D Landfill
Cabarrus County
4441 Irish Potato Road
Address
Concord NC 28025
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
http://deq.nc. gov/about/divisions/energy-mineral-land-resources/energy-mineral-land-permits/stormwater-program
and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Kevin Grant
First MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
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SW U-OWNERAFFI L-23March2017
Cyle Bilafer
First MI Last

NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
5) Reason for this change:
A result of:
If other please explain:
Area Manager of Operations
Title
PO Box 707
Mailing Address
Concord NC 28026
City State Zip
[phone] [e-mail]
Telephone E-mail Address
[phone]
Fax Number
❑ Employee or management change
® Inappropriate or incorrect designation before
❑ Other
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
I, Kyle Bilafer, 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.
Signature
PLEASE SEND THE COMPLETED FORM TO:
Division of Energy, Mineral, and Land Resources
Stormwater Program
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
11/14/17
Date
For more information or staff contacts, please call [phone] or visit the website at:
http://deq.nc. gov/about/divisions/energy-mineral-land-resources/stormwater
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SW U -OW N ERAFFI L-23Mar2017