NCG070189_Owner Affiliation Form_20180522

Divnion ofFnargy,Mhteol and" ad Rmourcm Cray
Land Quality Section I Stmmwafer Permilffng Program
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NCDMRNaaonni Pollutant Dimhurge Elimination Systam(NPDES)
PERMIT OWNER AFFILIATION DESIGNATION FORM
(IMWbunl Legally aesponaiWefir Pmmll)
H NO CHANGE m roMpapy or lacility ownership or name has xcurrad.
Na Name Ctmnge and/or Ownership Tranakr of Me /a0MY has prompted this change, do
NOT use this /orm. You must fill out Ne Name -Ownership Change Form antl pro✓Itla all
necessary supporting dowmentatfan instead.
I) Enter the permit aomber for which this change fn Legally Reapomfbk Individual (VOwner
A(flliWhm^)aPPlln:
Individual Pvmit I 1 eenllema ofCavxmga
b.I 6 6. 1 1
SI Facility Warrenton:
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k MEW by, Ro,51111111111111
To fiiW Ne cunmt legally responsible permit a iamd with your permit, go to thu wehsim:
hoprW de / h'I'w cu and run the Permit CantaerSumm.ry Repud.
)) QJ, DO R"MLIATIONt tmuWdbe[emared:
Pmlma leglly respamlblc individoel: SOP Clll&r-s
F m tea
d) NE'A'OWamR AFFIIJATION(dapfpmlmasibk for We permu):
Pomo legally rtspaalble for this parent
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NPOESStormwater Permit OWNER AFFILATION DESIGNATION Form
IJ no FAdmY NwM wMhip change)
5) Nnwo for thisohvniu:
A result of houtiyeeor nrenagemem change
cater apw
®le wcarrecldesigradmlbeforc
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Wimttloes "tepplly reaDolaiLle pavan" ni
That person is elther:
• the responsible corporxlc 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.
PERMrrrECERIWICAT1ON'.
1. V#aLl/' 0AJ none derides spnietlbn an ton enrage In Owren nmherion
lPeNrm Ingdly rests ibm frthe Parent has hen reviewed end is aeelnam anal nowplee is the hen ormy
Ynowidge- i antlel�d am Ifsa requhN Fans ofNis flan are rolwmplelhis change mut nal h
I � 51aa�8o)$
Sippaaue care
P� SEND TDE COMPLETED FORM TO:
Division ofEr�ven, Mineral mid Land RmwrteS
Stormwahr PvmitDeg Prapam
1612 Mail Service Center
Hviagh, hldW Carolire2'/EW-161?
For mom infrann ion in Sulrmnd plve vigil our website:
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