NCG210444_Owner Affiliation Change_10/16/2018

Division of Energy, Mineral, and Land Resources FOR AcsNcr uss ow.v
Land Quality Section / Stormwaterater Program
National Pollutant Discharge Elimination System (NPDES)
Enaryr. +' n PERMIT OWNER AFFILIATION DESIGNATION FORM
(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 name of the facility has changed, or if the ownershio 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:
• 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 (f°Owner Affiliation")
applies:
Individual Permit (or) Certificate of Coverage
N C S N C G 2 1 0 4 4 4
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
4300 Oak
Address
Sanford NC 27330
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
httv://deo nc gov/aboWdivisions/enc -mineral-land-reso=eslenerLY mineral land pe mits/stormwater ro otsam
and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Gray Armstrong
First MI Lest
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
5 WII-OWNERAFFI1-23M 1¢h201
Tony Mulcahy
First MI Last
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NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
Site Leader
4300 Oak Park Road
Mailing Address
Sanford NC 27330
City State Zip
(919 )'775-`7100i nnu m v� ea h "iterCov+l
Telephone E- ail Address
Fax Number
5) Reason for this change:
A result of: ❑� Employee or management change
13 Inappropriate or incorrect designation before
❑ Other
If other please explain:
.......-------------- ..... ..............................................................
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
Tony Mulcahy , 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.
02 ocr 20 1$'
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:hq://deg.nc.goy/about/divisions/energy-mineral-land-resources/stormwater
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S W U-OWNERAFF1423Mar2017