NCG120065_Owner Affiliation Change_20190322

NCDENR
NORTH C4 OUNA DEPARTMENT OF
ENVIRONMENT ANO N/mJ RESOURCES
Division of Energy, Mineral and Land Resources FOR AGENCY USE ONLY
Date Received
Land Quality Section / Stormwater Permitting Program Year Month Day
National Pollutant Discharge Elimination System (NPDES) i'
PERMIT OWNER AFFILIATION DESIGNATION FORM CPI f�
(Individual Legally Responsible for Permit) O
14 2nv
.11
if NO CHANGE in company or facility ownership or name has
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 C S
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
(or) Certificate of Coverage
N C G Z O , fO
vtN if oyGtZ-NAA_ F_'t3
1514 1�_LA13aNe5 ED,
Address
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
hqp://portal.ncdenr.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: �� A 0 Y— C L l T7-� 0 1�
First MI Last
4) NEW OWNER AFFILIATION (Legally responsible for the permit):
Person legally responsible for this permit:
SW U-OWNERAFFIL-22May2014
B o ,J t� 16 A k A P� E Q.5 L-6,
First MI Last
LD eA tJ1- `i IIJ\.A-►J AC -,<.\2
Title
PO &0x (� l 8 l
Mailing Address
, >JL Z�12t7�
City State Zip
24 S ` ZS75 b kctM,,LS le l
Telephone E-mail Address
Fax Number
Page 1 of 2

NPDESStormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
5) Reason for this change:
A result o£ LJ Employee or management change
❑ Inappropriate or incorrect designation before
❑ Other
If other please explain:
What does "legally responsible person" mean?
That 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 that person above.
The certification below must be completed and signed by the permit
holder.
PERMITTEE CERTIFICATION:
I, %0 tJ 0 l �-_ J 1 !KM LAOS LG'� , 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 ate
........................
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:
htip://portal.ncdenr.org/web/Ir/stormwater
Page 2 of 2
SW U -OW N ERAFFI L-22May2014

Orange County Solid Waste Management
P.O. Box 17177
Orange County Landfill 932-2989
Chapel Hill, NC 27516-7177 [phone] FAX [phone] www. co. orange.nc us/recycling
February 8, 2018
NC Division of Energy, Mineral and Land Resources
Stormwater Permitting Program
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
Re: Orange County MSW & C&D Landfills, NCG120065
Permit Owner Affiliation Designation Form
Orange Community Recycling 968-2788
Please find enclosed a completed Permit Owner Affiliation Designation Form. The form is
submitted to change the name of the legally responsible person to the current County Manager,
Bonnie Hammersley.
If you have any questions, please contact me at lclindley@oran eg countync.gov or 919-918-4915.
enc.
Sincerely,
1 / /
R. Kevin Lindley, PE
RECaf VD
FEB 13 2018
DENR-LAND QUALITY
STORMWATER PERMITTING