NCG210444_Owner Affiliation Change_8/3/2018

�livislon of Energy, Mineral, and Land Resources FOR AGENCY USE ONLY
Date Received
La -26 Quality Section / Stormwater Program Year MonthK- Day
National Pollutant Discharge Elimination System (NPDES)
Lnergy. Mineral a PERMIT OW�!ER .�,.FF FILIATIOH DESIGPnTICY FORM
Land Rewurres
*P0VW cAdit 14 t At �l 11 I 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 nam of the facility has changed, oe if the ownership of the facil&r has changed,
do HOT use this ®orm. Instaad, you must fill out a Alamo-®-Arnership Chancre Form
and submit the completed form °nigh all required docurnenation.
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
;m! C
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
(or) Certificate of Coverage
P I C I G 2 11 10 14 4 4
Wyeth, LLC
4300 Oak Park Road
Address
Sanford NC 27330
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
http://deq.nc. gov/about/divisions/energy-mineral-land-resources/energy-mineral-land-permits/storrnwater-prim
and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Charles E Powell, Jr.
First MI
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: Grey
Page I of 2
S WU-OWNERAF F IL-2 3 Marc h2017
First MI
Last
Armstrong
Last

syPDES Siormp}i+ate. Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
Interim Site Leader
Title
4300 Oak Park Road
Mailing Address
Sanford NC 27330
City State Zip
566-536b +rongRpTize acorn
Telephone Q E- ail Address
Fax Number
5) Reason for this change:
A result of: ® Employee or management change
❑✓ Inappropriate or incorrect designation before
❑ Other
If other please explain: X
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
I Gray Armstrong , 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.
Dat
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/stormwater
Page 2 of 2
S W U-OWNERAFFILr23Mar2017