NCG080128_Owner Affiliation Change_20171113

NCDENR
NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT AND N—RAL REsou ES
Division of Energy, Mineral and Land Resources FOR AGENCY USE ONLY
Date Received
Land Quality Section / Stormwater Permitting Program Year Month Day
National Pollutant Discharge Elimination System (NPDES)
PERMIT OWNER AFFILIATION DESIGNATION FORM
(Individual Legally Responsible for Permit)
if NO CHANGE in company or facility ownership or name has occurred.
If a Name Change and/or Ownership Transfer at the facility has prompted this change, do
NOT use this form. You must fill out the Name -Ownership Change Form and provide all
necessary supporting documentation instead.
1) Enter the permit number for which this change in Legally Responsible Individual ("Owner
Affiliation") applies:
Individual Permit
N C S g O l 2 8
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
(or) Certificate of Coverage
N C G
NoR-w;cAao+-zNA STATE: L)Pj+v-WAV_t
u C S—A-Te, L70 c�ZsS t�
CAMZ) ,'> 1S3Co
Address
►RAL_;_ -1y4 tx 2-7c,95
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
http://portal.ncdenr.org/web/Ir/sw-permit-contacts and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: 'SAc-K
First MI Last
4) NEW OWNER AFFILIATION (Legally responsible for the permit):
Person legally responsible for this permit: ANg Svrc-
first MI Last
CL ZS=1 %Z_ OF' Dc SLY,0 Au Z> CO +., STM t_xzn CM')
Title
CAmp(_>5 3ov-121t,o
Mailing Address
Ral.�t�►� tic. Z.7ep9!E�-
City State Zip
(91q) 51'0- C37y and -/-Snead .�i�7
Telephone E-mail Address
(q19 ) 515 -3395
Fax Number
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SWU-OWNERAF FIL-22May2014

NPDESStormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
5) Reason for this change:
A result of:
If other please explain:
What does "legally responsible person" mean?
That person is either:
�] Employee or management change
❑ Inappropriate or incorrect designation before
❑ Other
• 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:
I, , 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.
ll \3 17
Signature Date
PLEASE SEND THE COMPLETED FORM TO:
Division of Energy, Mineral and Land Resources
Stormwater Permitting Program
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
For more information or staff contacts, please visit our website:
http://portal.ncdenr.org/web/1r/stormwater
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SM -OW NERAFFI L-22May2014