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HomeMy WebLinkAboutNCG080328_Owner Affiliation Change_20181214Division of Energy, Mineral, and Land Resources Land Quality Section / Stormwater Program i� - National Pollutant Discharge Elimination System (NPDES) Energy. Mineral& PERMIT OWNER AFFILIATION DESIGNATION FORM Land Resources CNVIRONMCNTAL OUALITY (Individudl Leydlly Robpollbibib full P0111lil) Use this form if there has been: FOR AGENCY USE ONLY Date Received Year Month Day 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 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 (Gr) Certificate of Coverage N I C I S I I I I I N I C I G 2) Facility Information: Faculty name: Please see the attached spreadsheet for list of facilities & Certificates of Coverage Company/Owner Organization: Waste Management of Carolinas, Inc. Facility address: Please see attached spreadsheet for each facility address Addtcas City State Zip To find the current legally responsible person associated with your permit, go to this website: http://deg.nc. .ov/about/divisions/energymineral-land-resources/energy-mineral-land-permits/stormwater-pros ram and run the Permit Contact Summary Report. 3) OLD OWNER AFFILIATION that should be removed: Previous legally responsible individual: Steve Cobb First MI Last 4) NEW OWNER AFFILIATION (legally responsible for the permit): Pelson legally iesponslble tut llils peunit. K Eric Wakefield First MI Last Page 1 of 2 SWU-0WNERAFFIIr23March2017 NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form (if no Facility Name/Ownership Change) 5) Reason for this change - A result of: If other please explain: Area Director of Collections Title 13850 Ballantyne Corporate Place, Suite 225 Mailing Address Charlotte NC 28277 City State Zip ( 980 ) 337-5331 kwakefie@wm.com Telephone E-mail Address (NA ) Fax Number Employee or management change ❑ Inappropriate or incorrect designation before ❑ Other The certification below must be completed and signed by the permit holder. PERMITTEE CERTIFICATION: I K. Eric Wakefield , 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 p of this form are not completed, this change may not be processed. , _ 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 (919) 707-9220 or visit the website at: httt ://deg.nc.gov/about/divisions/enemy-mineral-land-resources/stormwater Page 2 of 2 S WU-OWNERAFF1,23Mar2017 k j k§ k k§§\ k( I [ § G & % , f - 4 | $ a]))) 7 6 i® a f / a § 2 ) ) / \ / ) [ § f £ \ 3 ) § ) a { / o � \ j 0 / r- E e a§\ 7 r&§@§ f p k k k k k k k k k k k ( { ( } } ( ( ( ( ( ( m f to co m» m S» w w 00000000000 0 0 0 0 o c o e c o 0 0 0 0 0 0 0 0 0 0 0 0 { z � � � � � \ � � �