NCG080879_Owner Affiliation Change_20181024

Division of Energy, Mineral, and Land Resources FOR AGENCY USE ONLY
Land Quality Section / Stormwater Program ram Date Received
Year Month Day
National Pollutant Discharge Elimination System (NPDES)
Energy, Mineral& PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resources
ENVIRONME, NTALDUALITY (Individual Legally Responsible for Permit)
Use this form if there has been:
NO CHANGE in facility ownership or facility name, but the individual
o is legally+1 rr 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:
• 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 (or) Certificate of Coverage
N C S I I I I N I C I G 10'g 10 g 1119 1
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
On ►� Clv� b 4k L',.,pt VA'kLle.
ID31 A-h'a,,nd® AWcnJc
Address
01 AX 6"t- t.1G 21 TV)
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
littp:Hdeq.nc.gov/about/divisions/energy-mineral-land-resoul•ces/energy-miiieral-land-permits/stormwater-program
and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Hart.' Aq 1%r)
Fifft M1 Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Pelson legally responsible for this permit: M11 ke- -D&J; S
First MI Last
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S WU-OWNERAFFIL23March2017

NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
C l y► GO.I A6 -Lr
Title
X o C wtor - 4* C?M
/� �® Mailing Address
( /y1 Ni 1-o W— N (e $ Z.O Z•
City State Zip
(10� ) 13b 393V
Telephone E-mail Address
Fax Number
5) Reason for this change:
A result of- d 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:
1, t S lC4�_ �G ``{-�� , attest that this application for this change in Owner Affiliation
(person legally responsible for tW 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.
10 23� ig
Signatur 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.ne.gov/about/divisions/energy-mineral-land-resources/stormwater
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S WU-OWNERAFF11,23Mar2017