NCG160191_Owner Affiliation Change_20190522

Division 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
EN"ONMEWAL OUAUTY (Individual Legally Responsible for Permit)
Use this form if there has been:
FOR AGENCY USE ONLY
Dale Reccived
Yeu
Mwth
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 fonn. 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 I C I S71 N I C I G 11 16 10 11 9 1
2) Facility Information:
Facility name: Harnmaker East Black Mountain
Company/Owner Organization: Hammaker East LTD
Facility address: 1561 Gravestone Road
Address
Black Mountain NC 28711
City state Zip
To find the current legally responsible person associated with your permit, go to this website:
http://deg.nc.izov/about/divisions/enerey-mineral-land-resources/egg&-mineral-land-permiWstormwater-program
and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Joseph S Byram
First bII Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: Andrew Levenson
First tvtt Last
Page 1 of 2
S W U-OWNERAFF1L23Marc62017

NPOES Storinwaftw Parmit OWNER AFFILATION DESIGNATION Form
(if no Facility NameA)wnenhip Cbange)
Plant Manager
11de
1561 Grovestone Road
Mdt1nQ Address
Black Mountain NC 28711
Pity Slate Zip
828 ) 68&3011 andrew.levenson®hammakemast.com
Telephone E-inail Address
(828 ) 686-3014
Fax Number
5) Reaaoa for this change:
A result of: 0 Employee or management change
0 Inappmpriate or incorrtxt designation before
❑ Other
lforherpkwe explain:
.............................................................................................................. 4....6
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
1, Tom Huet , 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. 1 understand that if all required parts of this form are not completed, this change may not be
pwessed•
c4J Sr 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: http://deg.nc.gov/about/divisions/energy-mineral-land-resources/stormwater
Pagc 2 of 2
5WU-0WNFRMFR.23 &r20l7