NCG050168_Owner Affiliation Change Form_20180814

AIS
NCDENR
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)
FOR AGENCY USE ONLY
Date Received
Year
Month
I Day
• , r • .. y, • _ •,
•. •. - • • •--a
NOT • You • • Change Form and provide aH
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 I I I I I
2) Facility Information:
Certificate of Coverage
Facility name:�,a<_LtCi Legh 26 Vi,aa .
Company/Owner Organization:
Facilityaddress: ( knneA?t>C I�&
��� ddress
.$tom NC. CMS9
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
http://portal.ncdennorg web/Ir/sw-permit-contacts and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: J �t'ocl
First NU LAst
4) NEW OWNER AFFILIATION (Legally responsible for the permit):
Person legally responsible for this permit:
=Mailirl��.
Telephone E-mail Address
Fax Number
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NPDESStormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
5) Reason for this change:
A result of: LVJ Employee or management change
❑ Inappropriate or incorrect designation before
❑ Other
Ifother please explain:
What does "legally responsible person" mean?
a• y
® 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:
;S attest that this application for this change n Owner Affiliat on
(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
Signature
W�!
Date
PLEASE SEND THE COMPLETED FORM TO:
Division of Energy, Mineral and Lan
d Resources
Stormwater Permitting Program
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
For more information or staff contacts, pleas
e visit our website:
httn: rtal. ncdenr. or'Jweb/lr/stormwater
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