NCS000482_Ownership Change Form_20180813

Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
Energy. Mineral & PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resources
ENVIRONMENTAL QUALITY (Individual Legally Responsible for Permit)
Use this form if there has been:
FOR AGENCY USE ONLY
Date Received
Year
Month
Day
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: RECEIV�J
• the responsible corporate officer (for a corporation); l�
• the principle executive officer or ranking elected official (for a municipality, state, fedeq�l�sr gtlker„pytji is
agency); ri1117 1 ei [f1
• the general partner or proprietor (for a partnership or sole proprietorship); DENR-LAND QUALITY
• or, the duly authorized representative of one of the above. ST0RMVVATER PERMITTING
1) Enter the permit number for which this change in Legally Responsible Individual ("Owner Affiliation")
applies:
Individual Permit (or) Certificate of Coverage
N I C I S 10 10 10 14 1 N I C I G
2) Facility Information:
Facility name:
Company/Owner Organization
Facility address:
Monroe City -Small MS4
City of Monroe
300 West Crowell Street
Address
Monroe NC 28111
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/stormwater-program
and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: James
L. Loyd
First MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
S WU-OWNERAFFIL-23March2017
E. L. Faison
First MI Last
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NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
City Manager
Title
PO Box 69
Mailing Address
Monroe NC 28111
gate Zip
[phone] [e-mail]
iciepiiuuc E-mail Address
((704))282-9098
Fax Number
5) Reason for this change:
❑ Employee 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 CERTIFICATION:
I, t. Lw -r( 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
knowled I understand that if all required parts of this form are not completed, this change may not be
processe .
��• la
Signature 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/stormwater
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S W U-OWNERAFF ILL23Mar2017