NCG030627_Owner Affiliation Change Form_20181127

Division of Energy, Mineral and Land Resources FOR AGENCY USE ONLY
,� �,! Land Quality Section / Stormwater Permitting Program Year MonthDate Day Day
NCDENR National Pollutant Discharge Elimination System (NPDES)
N��
owr+i CJAOI.IIM DQ AR�MCNT OF PERMIT OWNER AFFILIATION DESIGNATION FORM CE/VEp
ENVIRONMEHt IJ+O N�vuru� Resouwccs
(Individual Legally Responsible for Permit) APR 2 6 AM
Use this form if there has been:uTORMWq�R p UALITY
NO CHANGE in facility ownership or facility name, but the indiviauaiRM11TING
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 rill 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 ISI
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
(or) Certificate of Coverage
N I C I G 10 1 3 1 a 1 &7[7,
Cc, -I k,", -1 C.,n
7E_r n -)-_Y,_ J (�D �
Address
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
http://portal.ncdenr.org/web/Ir/sw-pennit-contacts and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: �e_44 4 AS_ec
First MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit
SM-OWNE RAFFI L-25July2014
k�jdrt C_ Clot k-,
First MI Last
K oc+nay C(a.rl,
Page 1 of 2

NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
Title
-
`ur
p Mailing Address _
cti e,� tV L
7Z�,3 1 J
City State Zip
(
0/l0) 94/c/-Vlao . c.krkc
Telephone E-mail Address
Fax Number
5) Reason for this change:
A result of: LJ 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, �n,n a C_" , 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
pro es d.
�IIZ3/ij
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.ncdenr.org/web/lr/stonnwater
p
Page 2 of 2
S W U -O W N E RAF F I L -25J u l y2014