NCG210408_Owner Affiliation Form_20180627

Division of Energy, Mineral, and Land Resources FOR AGENCY USE ONLY
Land Quality Section 1 Stormwater Program Year I DatMived
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National Pollutant Discharge Elimination System (NPDES)
Energy, Miner" PERMIT OWNER AFFILIATION DESIGNATION FORM
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FHVIYONMEki AI WAN +T'T (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 J C I 5
2) Facility information:
Facility name:
Company/Owner Organization:
Facility address:
(or) Certificate of Coverage
N I C I G 1 10 14 0$
Snow Hill Chip Mill
International Paper Complany
335 Jesse Hill Road
Address
Snow Hifi NC 28580
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
h :Ilde .nc. ov/about/divisionslener -mineral-land-resources/oner -mineral-land- e mits/stortnwater-12rojzram
and run the Permit Contact Summary Report.
3) ULD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Mark
S Sutton
First MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
Jim F Durhamn
First Mt Last
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SWU-0WPiERAFFIL-23March2017

N P D E S Stormwater Permit OWNER AFFILATION DESIGNATION Farm
(if no Facility Name/Ownership Change)
Fiber Supply Manager
Title
865 John L. Riegel Road
Mailing Address
Riegelwood NC 28456
City State Gip
910 352-474x3 iim.durhaM inaDer.cam
Telephone E-mail Address
(910 )342-2869
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 mulst be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
I, Jim Durham , 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 allrequired parts of this form are not completed, this change may not be
processed. , ,, X -"i
06/27/2018
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: http://deg.ne.gov/about/divisions/energy-mineral-land-resources/storrnwater
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SWU-0WNERAFFIL-23Mar2017