NCG030635_Owner Affiliation Change_20180927

Division of Energy, Mineral, and Land Resources FOR ACENIY USE ONLY
on ormwaProgram Land Quality Section / Stter Pram Date Received
•,, Year Month Day
N ro National Pollutant Discharge Elimination System (NPDES)
Energy. Mineral d PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resources (Individual Legally Responsible for Permit)
L anO Reso rces
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 name of the facility has changed, or if the ownership of the facility has changed,
do NOT use this form. Instead, you must rill 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)
Penco Products Inc
1301 Penco
Certificate of Coverage
N C G O 3 0 6 3 5
Address
Hamilton NC 27840
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/stonTiwater-program
and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Corey
First
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: Ronny
SW U-OWNERAFFtL-23March2017
Risden
Cottle
First MI

NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
Plant
Title
1301 Penco Drive
Mailing Address
Hamilton NC 27840
City State Zip
(252 )7984000 [e-mail]
Telephone E-mail Address
(252 )7985000
Fax Number
5) Reason for this change:
A result of: El Employee or management change
® Inappropriate or incorrect designation before
❑ Other
If other please explain:
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
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 fort are not completed, this change may not be
process p
(( l /Z-7 /Zo 1 3
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:Hdeg.nc.gov/about/divisions/energy-mineral-land-resources/stonnwater
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SW U -OW NERAFFIL-23Mar2017