NCG050270_Owner Affiliation Change Form_20180713

Division 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
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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 [phone] or visit the website
at: http://deg.nc.gov/about/divisions/energy-mineral-land-resources/stonnwater
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S WU-OWNE RAFF IL-2 3 Ma r2017