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HomeMy WebLinkAboutNCG050270_Owner Affiliation Change Form_20180713Division of Energy, Mineral, and Land Resources Land Quality Section / Stormwater Program FOR AGENCY USE ONLY Date Received Year Month Day National Pollutant Discharge Elimination System (NPDES) RECEIVED Energy, Mineral & PERMIT OWNER AFFILIATION DESIGNATION FORM Land Resources JUL ENVIRONMENTAL QUALITY (Individual Legally Responsible for Permit) 13 2818 DENR-LAND QUAL ITY Use this form if there has been: STORMWATER PEW rTINi 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 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 I C G Aapol­ Y'e(ol- � + Vn rvl G - ZCSO raw oro( Road Address S� SVIW-e A& ZS�Z.S City State Zip To find the current legally responsible person associated with your permit, go to this website: http://deg.nc.gov/about/divisions/energy-mineral-land-resources/energy-mineral-land-permits/stormwater-program and run the Permit Contact Summary Report. 3) OLD OWNER AFFILIATION that should be removed: Previous legally responsible individual: ,'K V1"e a rm 2 First MI Las 4) NEW OWNER AFFILIATION (legally responsible for the permit): Person legally responsible for this permit: 90 V1 a- /W M, A, Aie10+ First MI Last Page 1 of 2 S WU-OWNERAF FIL-23 Marc h2017 NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form (if no Facility Name/Ownership Change) Title Mailing Address f.�1Ville ,(/C- z s' City State Zip (7o 1) 978- 0//4/ emaY. #aAlhr'.e 9#A0oG,co Telephone E-mail Address ( X04) 978 - 0138 Fax Number 5) Reason for this change: [dEmployee or management change A result of: Inappropriate or incorrect designation before ❑ Other If other please explain: The certification below must be completed and signed by the permit holder. PERMITTEE 90/k CERTIFICATION: I,VIQ(dl U� 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. SignOr 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 (919) 707-9220 or visit the website at: http://deg.nc.gov/about/divisions/energy-mineral-land-resources/stonnwater Page 2 of 2 S WU-OWNE RAFF IL-2 3 Ma r2017