NCG030605_Update for Responsible Official_20190117

McCoy, Suzanne
From: Loyd, Danielle <[e-mail]>
Sent: Thursday, January 17, 2019 10:50 AM
To: McCoy, Suzanne
Subject: [External] Update for Responsible Official
Attachments: Responsible Offical Change NCG030605.PDF
External email. Do not click links or open attachments unless you verified. Send all suspicious email as an attachment to
[e-mail]
Hi Suzanne,
I have attached our update for Responsible Official. Please let me know if you need anything else. Thanks!
Danielle Loyd
Environmental Health & Safety Engineer
[phone] x 3506 mobile [phone]
Moog Industrial Group
1995 NC HWY 141
Murphy, NC 28906 USA
www.mooq.com
This document does not contain Technical Data or Technology as defined in the ITAR Part 120.10 or EAR Part 772

Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
- National Pollutant Discharge Elimination System (NPDES)
Energy, Alin eral& PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resources
PO rONMENTAL WALIT7 (Individual Legally Responsible for Permit)
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
N IC ISI
Z) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
(or) Certificate of Coverage
N I C 1 13 10 16 10 5
Moog, Inc.
1995 NC Hwy 141
Address
Murphy NC 28906
City state zip
To find the current legally responsible person associated with your permit, go to this website:
htt;,'ideg.nc.l;ovlabout'divisions;'ener, -mineral-land-resources'enerity-mineral-Iand-permits stormwater-proLyram
and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Terry
First MI
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person Iegally responsible for this permit: Scott
First MI
Martin
Last
Keaton
Last
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NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
General Manager
Title
1995 NC Hwy 141
Mailing Address
Murphy NC 28906
City State Zip
(828 ) 837-5115 [e-mail]
Telephone E-mail Address
Fax Number
5) Reason for this change:
A result of ✓❑ Employee or management change
El Inappropriate or incorrect designation before
❑ Other
If other please erplain:
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
1, Danielle Loyd , 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.
t� 1 /17/2019
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: htt :/ de .nc. ov/about/div*tsionsiener -mineral-land-resources`stormwater
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