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HomeMy WebLinkAboutNCG150029_Owner Affiliation Change_20190208Division of Energy, Mineral, and Land Resources Land Quality Section / Stormwater Program K. National Pollutant Discharge Elimination System (NPDES) Energy. Mineral & PERMIT OWNER AFFILIATION DESIGNATION FORM Land Resources ENVIRONMENTAL QUALITY (Individual Legally Responsible for Permit) Use this form if there has been: FOR AGENCY USE ONLY Date Received Year Month Da NO CHANGE in facility ownership or tacility 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 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 N C G j'C; p p2 y 2) Facility Information: Facility name: /MkE Company/Owner Organization: /T16, . l�/=� t ���j T� Facility address: �' G - Address 642T AI67C AlG City State Zip To find the current legally responsible person associated with your permit, go to this website: littp:iIdeq.i)c.gov/° about/divisiolls/ietiergy-mineral-la:id-resources/energy-mineral-land-permitsfstormwater-program and run the Permit Contact Summary Report. 3) OLD OWNER AFFILIATION that should be removed: Previous legally responsible individual: ; J611 Z,si hhlee fT First MI Last 4) NEW OWNER AFFILIATION (legally responsible for the permit): Person legally responsible for this permit: First MI Last Page 1 of 2 S WU-OWNERAFFILr23NUrch2017 NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form (if no Facility Name/Ownership Change) Title Mailing Adc ess CAI f%4�� C— City State Zip �110) G>02 -3'9� Telephone E-mail Address (9/o) 1g,6 -og13 Fax Number 5) Reason for this change: A result o£ Employee or management change ❑ Inappropriate or incorrect designation before ❑ Other If other please explain: ........................... ...................... .....ik....... :i..a.............. r......................... ............ The certification below must be completed and signed by the permit holder. PERMITTEE CERTIFICATION: I, -7�;/4 �'l e �c,� . 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. Signature PLEASE SEND THE COMPLETED FORM TO: Division of Energy, Mineral, and Land Resources Stormwater Program 1612 Mail Service Center Raleigh, North Carolina 27699-1612 Date For more information or staff contacts, please call (919) 707-9220 or visit the website at: hil ://de .ne. rov/about/divisions/ene[g -mineral-land-resources/stormwater Page 2 of 2 S WU-OWNERAFFIIr23Mar2017