NCG080822_Owner Affiliation Change_20181024

Division of Energy, Mineral, and Land Resources FOR AGENCY USE ONLY
Date Received
Land Quality Section / Stormwater Program Year Mentz, Day
w National Pollutant Discharge Elimination System (NPDES)
Energy, Mineral & PERMIT OWNER AFFILIATION DESIGNATION FORM
LandResources
ENVIRONMENTAL 0UAL11Y (Individual Legally Responsible for Permit)
Use this form if there has been:
NO CHANGE
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:
• 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 SI I I I F N C G®$® g 2
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
Address
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: RAPAJ Hari�yi�
First MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
S WU-OWNERAFFIIr23March2017
Mi KL
First MI
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Last

NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
C1,�nglnGcr
Title
Mailing Address
NL 2g2o2.
City State Zip
(toy) 33b -393g M6kAA''i5' 8, e;.cWA+c.vw.us
Telephone E-mail Address
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 WS b1 R t't `' ""attest that this application for this change in Owner Affiliation
(person legally responsible for he 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.
I
Q Ib)23�18
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•//deq nc gov/about/divisions/energy-mineral-land-resources/stormwater
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S W U-OWNERAFFlLr23Mar2017