NCG080286_Owner Affiliation Form_20171117

F15WA
MOM E 1`40 R
NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT AND NATURAL RESOURCES
Division of Energy, Mineral and Land Resources FOR AGENCY USE ONLY
Date Received
Land Quality Section / Stormwater Permitting Program Year Month Day
National Pollutant Discharge Elimination System (NPDES)
A -
if NO CHANGE in company or facility ownership or name has occurreed.
If a Name Change andlor Ownership Transfer at the facility has prompted this change, do
NOT use this form. You must fill out the Name-OvInership Change Form and provide all
necessary supporting documentation instead.
1) Enter the permit number for which this change in Legally Responsible Individual ("Owner
Affiliation") applies:
Individual Permit (or) Certificate of Coverage
N I C I S I I I I I I I I N I C I G 1 018 8 1 0 1 2 1 8 1 6
2) Facility Information:
Facility name: Advantage Machinery Services - Charlotte Division
Company/Owner Organization: Advantage Machinery Services
Facility address: 3027 North Tryon Street
Address
Charlotte NC 28206
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
int r, . //partaLnedenr, org/web/lr/ and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: None
First Ml Last
4) NEW OWNER AFFILIATION (Legally responsible for the permit):
Person legally responsible for this permit: Mark R Gallimore
First Ml Last
President
Title
PO Box 1848
Mailing Address
Yadkinville NC 27055
City State Zip
336 ) 463-4700 [e-mail]
Telephone E-mail Address
336 ) 463-2440
Fax Number
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noName/Ownership
5) Reason for this change:
A result of: ❑ Employee or management change
❑ Inappropriate or incorrect designation before
Other
If other please explain
Owner affiliation not listed with a contact name
What does "legally responsible person" mean?
That person is either:
the responsible corporate officer (for a corporation);
the principle executive officer or ranking elected official (for a n1unicipality,
State, Federal, or other public agency-);
thegeneral 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 perm
i
1 Mark Gallimore , 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
Division of Energy, Mineral and Land Resources
Stormwater Permitting Program
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
11/17/17
M
For more information or staff contacts, please visit our website:
http://portal.ncdenr.or�tww-eb/hr/stormwater
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