NCG210115_Owner Affiliation Form_20180702

Division of Energy, Mineral, and Land Resources FOR AGENCY USE ONLY
Date Received
Land Quality Section / Stormwater Program Year Month Day
- National Pollutant Discharge Elimination System (NPDES)
Energy, Mineral & PERMIT OWNER AFFILIATION DESIGNATION FORM ,l(J� 0� V ��
Land Resources
ENVIRONMENTAL QUALITY (Individual Legally Responsible for Permit)
OFn�o . B
ti L�
Use this form if there has been: �R44,qTFRpUI411Y
NO CHANGE in facility ownership or facility name, but the individual Ml�/RG
. who is legally responslble-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 fill 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 I C I S
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
(or) Certificate of Coverage
N C G 2 11 lo 11U 5]
Elkin Facility
Weyerhaeuser NR Company
524 Pride Way
Address
Elkin NC 28621
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
http•//dgq.ne. gov/about/divisions/energy-mineral-land-resources/energy-mineral-land-permits/stormwater-projzram
and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual:
Dennis
First
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
S WU-OWNERAFFIL-23 March2017
R Atkinson
M1 Last
Ross
First MI
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Gardner
Last

NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
Mill Manager
Title
524 Pride Way
Mailing Address
Elkin NC 28621
City State Zip
( 336 ) 526-6494 ross.gardrter(gweyerhaeuse&,i�Dm
Telephone E-mail Address
r 336 ) 8,35-7 183
Fax Number
5) Reason for this change:
A result of: ✓❑ Employee or management change
Inappropriate or incorrect designation before
❑ Other
If other please explain: Mill Manager retired
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
1 Ross Gardner , 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
processe
C ZL
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:/ideg.nc.gov/about/divisions/energy-mineral-land-resources/stormwater
Page 2 of 2
S WU-OWNERAFFIL-23 Ma r2017