NCG070086_Owner Affiliation Form_20180530

Division of Energy, Mineral, and Land Resources FOR AGENCY USE ONLY
Dale Recen'ed
Land Quality Section / Stormwater Program Year htonlh oa
National Pollutant Discharge EIimination System (NPDES)
Energy. Alineral a PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resources
ENVIRONMENTAL qII ALIT (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 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 17 10 10 R:6]
Resco Products, Inc
Resco Products. Inc.
3800 West Wendover Avenue
Address
Greensboro NC 27407
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
htt ://de .nc. ,ov/about/divisions/ener v-mineral-land-resources/ener rv-mineral-land- ermits.stormwater- ro rram
and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Alex Ford
First MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
Graham McDonough
First MI Last
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NPDES Stotmwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
5) Reason for this change:
A result of:
If other please explain:
Corporate Controller
Title
One Robinson Plaza, Ste 300, 6600 Steubenville Pike
Mailing Address
Pittsburg PA 15205
City State Zip
wo ylaliclttl.mt;uuiiuuyii�w -scup
Telephone E-mail Address
Fax Number
❑✓ Employee or management change
0 Inappropriate or incorrect designation before
❑ Other
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
1,6 R4L40 fft` n1o6/t ff �, 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.
'}C&
Signature [date
PLEASE SEND THE COMPLETED FORM TO:
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
For more information or staff contacts, please call [phone] or visit the website
at: htt :rlde .nc.�-,ov/about/divisions/ener2v-mineral-land-resources,'stormwater
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