NCG030675_Owner-Affiliation-Change

Division of Energy, Mineral, and Land Resources 1 FORA6ENCY 03E ONLY
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Land QualitySection / Stter Program Date Received
Q `.r g Year Month I Day
N Ira 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 (or) Certificate of Coverage
N I C I S I I I N I C I G 03 0 6 7 5
2) Facility Information:
Facility name: REV Re - mou4+ Ce.34-e tL
Company/Owner Organization: 011ILo¢6 &0-00P /rle, - AW1941A.J mar
Facility address: ✓ek- ./u 44rmegwt /D/ ACV L�. a -r.,,
Address
SC�eg 286 V0
City State zip
To find the current legally responsible person associated with your permit, go to this website:
http://deq nc gov/abouL/divisions/enerey-mineral-land-resources/enerev-mineral-land-permits/stormwater-IroVram
and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: VP- tjk 3/aRVE/L
First Ml Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
S W U -O WNERAFFIL-23March2017
Sec� I> P 6V e-tt-
First MI Last
Page 1 of 2

NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
Q.EcI'o2 of is lj (2alagi
Title
/b S AMati cAa k/41
Mailing Address
�cf(Yi NJ C.
City State Zip
( 33G )SdG-BOIo zefl=.ci1Re tc¢ aeV .Com
Telephone E-mail Address
( M ) qd 2- -7203
Fax Number
5) Reason for this change:
A result of: ❑ ployee or management change
Lff 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, 3'eff >R6 y gFR , attest that this application for this change in Owner Affiliation
(person legally responsibl r the permit) has been reviewed and is accurate and complete to the best of my
knowledge. I understand that it N required parts of this form are not completed, this change may not be
processed. n I
Date
PLEASE SEND THE COMPLETED FORM TO:
Division of Energy, Mineral, and 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:
hqp://deq.ne.gov/about/divisions/energy-mineral-land-resources/stormwater
Page 2 of 2
8 WU-OWNERAFF 1r23 Mat2017

NC Division of Energy, Mineral and Land Resources
NPDES Stormwater Permit Contacts Summary
NCDF NILR has the folluwin- contact information in our Permit Database for, our permit as of 10/13/2017
Permit Number:
NCG03067S
Permit Type:
Metal Fabrication Stomnvater Discharge COC
Facility Name:
REV Remount Center
Facility Addressl:
101 Aev Ln
Facility Address2:
Formally 101 Gates Ln
City, State & Zip:
Jefferson NC 28640
Owner Information Details:
MUST submit a Change of Name/Ownership form to DEMUR to make any changes to this Owner information.
See "Miscellaneous Forms" at htty://Dortal.ncdenr.org/web/[r/n[)des-stormwater
Permit Contact Persons)
___- _______ _ __ t4Ai Cori' I�RoVP 6x- ArneucA) geo-ss.a.7(1L4wolk,f Aerno o nl-i-.
Owner Name:
Owner Type:
Non -Government Owner Type Group: Organization
Phone Em
*•• Legally Responsible for Permit ***
(rfluyl..:.rs.
0 m`- 4jCf
(Responsible corporate officer/principle executive officer or ranking elected official/general partner or proprietor,
3 "9�-�7103
or any other person with delegated signatory authority from the legally responsible person.)
Owner Affiliation:
/-
-,.c n--eemri� SerthF ba.ye/ Title: ,�� of /Yi,oNOTACM1-VCrN&.
Addressl:
101 Aev Lane Formally 101 Gates Ln
Address2:
City, State & Zip:
Jefferson NC 28640
Work Phone:
42"46 334-8q4- '9611p Fax: [phone]
Email Address:
gar/.oarvbeaI(aa aev corn
Owner Contact Person(s)
Contact Name
Title Address Phone Fax Email
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Facility Contact Person(s)
Contact Name Ti lenA �//
Address
Phone fluEll
i
Kept Awl(@�+ 1 �`r'"P"�K
941,4 Grra.l6eA) raarfle-
101 Aev Lane Formally 101 Gates Ln,
..-+�oRaf+-i-'.?+_ 336-982-9826
gary.garybeal@ae�
3efferson, NC 28640
3'J6 477.7203
om
Permit Contact Persons)
Contact Name Title
Address
Phone Em
Email
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fol /d6V bs-,J9r
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3 "9�-�7103
9..r 19041
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Permit Billing Contact
Contact Name TTrfi le A dr s Phone FU Email
,.c+"'.-� Mp �R"uY 101 Aev Lane Formally 101 Gates Ln, T36-846-� 336-982-9826
'Se Vr6yex Jefferson, NC 28640 336'444 Solo _em..
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