NCG210396_Owner Affiliation Change Form_20180710

Division of Energy, Mineral and Land Resources
Land Quality Section / Stormwater Permitting Program
National Pollutant Discharge Elimination System (NPDES)
PERMIT OWNER AFFILIATION DESIGNATION FORM
(Individual Legally Responsible for Permit)
POR AGENCY USE ONLY
Date Received
7'car
I Month
I Day
Responsible Individual ("Owner
Affiliation")
necessary supporting documentation instead.
1)
Enter the permit
number
for which this change in
Legally
Responsible Individual ("Owner
Affiliation")
applies:
Individual Permit (or)
N C S
2) Facility Information:
Certificate of Coverage
MMMMMM
Company/Owner Organization:
Facility address: 7 9 5 wy ) 1
Address
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
http://portat.nedenr.org/web/lr/sw-permit-contacts and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: T^k�4�
First MI Last
4) NEW OWNER AFFILIATION (Legally responsible for the permit):
Person legally responsible for this permit: bl-
�j / First MI Last
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SW U-OWNERAFFIL-22May2014
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City State Zip
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'telephone E-mail Address
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Fax Number
age 1 of 2

NPDESStormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
5) Reason for this change:
A result of: Employee or management change
❑ Inappropriate or incorrect designation before
❑ Other
If other please explain: Ty, o awVv r ri(rZ� 4A
What does "legally responsible person" mean?
® 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 that person above.
.....................................................................................................................
The certification below must be completed and signed by the permit
holder.
PERMITTEE CERTIFICATION:
j-, n2r,nd�5 ,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.
ignature Date
.....................................
PLEASE SEND THE COMPLETED FORM TO:
Division of Energy, Mineral and Land Resources
Stormwater Permitting Program
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
For more information or staff contacts, please visit our website:
httna/portal.nedenr.oru�/web/hlstormwater
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SW U -OW NERAFFIL-22May2014