NCG080948_Owner Affiliation Change_20180124

RECEIVED
JAN 24 2018
Division of Energy, Minera ces FOR AGENCY USE
ONLY
iffDate Received
Land Quality Section / KW PMATMG
Year Month Day
National Pollutant Discharge Elimination System (NPDES)
Energy Aluierc+t PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resources
.1:VJr10 :rtenrn,t GUALI , (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 ranldng 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 (01) Certificate of Coverage
N I C I S I I I I I I I I N I C I G 1 U 1 13 1 01.1
2) Facility Information:
Facility name: IrcivtScA¢y S(zct^v,ck.s — Liok Mr,, -%J Services
Company/Owner Organization: i , cs -jec V S i- v =s Zoic
Facility address: 2s o i ?'v o lcr- poo.
Address
13Vrf�Me tUdj /�A(Z. Z7•ZiC,
Cy State Zip
To find the current legally responsible person associated with your permit, go to this website:
http //deg nc gov/about/divisions/energy-mineral-land-resources/energy-mineral-land-permits/storm,.vater-program
and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: 1.4 COL Lr\, I`l i coo (S
First MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: R J0 ({ j {C. jp rC-- Ljj
First MI Last
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SWU-OWNERAFFIL-23March2017 I ,) �jyQ
W

NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
�'evirc.rcz.l /YlctihciclF�
Tine
z�3c, i Tr�xly� toonj
Mailing Address
ii r+ n Cri'iy: j /y C Z'i z 1_';
City State Zip pp
(33G) 417-5340 c -A k'I I�E�rerc7(�,`trcvscfcv_ Gc.vl
0
Telephone E-mail Address
Fax Number
5) Reason for this change:
A result of: tK Employee or management change
❑ 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, Ra.b k i l i , 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
prcessed.
Signa ure 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:
hitp:Hdeq.nc. gov/about/divisions/energy-mineral-land-resources/stoi-mwater
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S WU-OWNERAFFIL-23Mar2017