NCG030504_Owner Affiliation Change_5/30/2019

Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
Energy, Minerut PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resource: ENVIRONMENTAL OUtI LI' (Individual Legally Responsible for Permit)
FOR AGENCY USE ONLY
Date Received
Year
Month
Day
Use this form if there has been:
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 `41egally 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 C S
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
(or) Certificate of Coverage
N I C I G 10 13 10.15 10 4
Flowserve US, Inc. - Raleigh
Flowserve US, Inc.
1900 South Saunders Street
Address
Raleigh, NC 27603
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
http://dgq.nc. ov/about/divisions/energy-mineral-land-resources/eneM-mineral-land-permits/stormwater-program
and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previo4s legally responsible individual: Robert Sherman
First MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: Helm Hansen
First MI Last
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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:
General Manager
Title
1900 South Saunders Street
Mailing Address
Raleigh, NC 27603
City State Zip
( 919 ) 831-3314 [e-mail]
Telephone E-mail Address
/ 919 1 831-3284
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, Helm Hansen , attest that this application for this change in Owner Affiliation
(person legglly 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.
5/30/19
—?
L;i
e Date
PLEASE SEND THE COMPLETED FORM TO:
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
14or more information or staff contacts, please call [phone] or visit the website
al: http://deg.nc.gov/about/divisions/energy-mineral-land-resources/storrnwater
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