NCG050174_Owner Affiliation Change_20180305

Division of Energy, Mineral, and Land Resources FOR AGENCY USE ONLY
Date Received
Land Quality Section / Stormwater Program 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 addres RECEIVED
(or) Certificate of Coverage
N C G 0 5 0 1 7 4
Georgia Pacific Corrugated, LLC
Georgia Pacific Corrugated, LLC
200 McDowell Rd
Address
MAR 0 5 2013 Asheboro NC 27203
City State Zip
DENR-LAND QUALITY
rR pmt�y91TTING
To find the currentg L%Upsible person associated with your permit, go to this website:
httD:Hdea .ne. cov/about/divisions/enerv-v-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:
Bev L Franks
First
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: Charles
First
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SWU-OWNERAFFIL-23March2017
MI Last
E Wells
MI Last
i

NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
5) Reason for this change:
A result of:
x
If other please explain:
Director of Operations
Title
200 McDowell Rd
Mailing Address
Asheboro NC 27203
City State Zip
(336) 3181340 cewells crgapac.com
Telephone E-mail Address
(336)6260917
Fax Number
X 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, Charles E Wells, 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 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:
http://decq.nc. gov/about/divisions/energy-mineral-land-resources/stonnwater
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SWU-OWNERAFFIL-23Mar2017