HomeMy WebLinkAboutNCG030505_Rescission Request_20180430NCDENR
NORTH CAROLINA DEAARTMENT or
ENVIRONMENT AND NATiI RnacE5
Division of Energy, Mineral and Land Resources
Land Quality Section 1 Stormwater Permitting Program
National Pollutant Discharge Elimination System (NPDES)
PERMIT OWNER AFFILIATION DESIGNATION FORM
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FOR AGENCY USE ONLY
Date Received
Year Month I Day
RecelveD
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Lei Hf LAN1Did. !
Use this form if there has been; STORMW QUA r
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: !�Ae1411ic • the responsible corporate officer (for a corporation);���• the principle executive officer or ranking elected official (for a municipality, state, r r
agency); dFIV Vie
• the general partner or proprietor (for a partnership or sole proprietorship);
• or, the duly authorized representative of one of the above. �FRpCl�,
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
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Ad rens !N
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City State Zip
To find the current legally responsible person associated with your permit, go to this website:
http:1/portal.ncdenr.org/web/ir/sw-permit-contacts and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: ja&ho-A dar-hn
First Ml tast
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
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&I- H. 5%0-ne.
First M1 Last
Page l of 2
NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
I
rr % Title
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Mailing Xddress
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City State Zip
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Telephone h -mail Address
(104 ) 893-11151
Fax Number
5) Reason for this change:
A result of: 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, / L,-,,� -s " , 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. ,4/
Y l�
Signature Date
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 call 919-707-9220 or visit the website at:
http://portal.nedenr.orWweb/Ir/stormwater
Page 2 of 2
SW U -0W NERAFFI L -25J u 1y2014