NCG120056_Owner Affiliation Change_20190208

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Energy. Mineral &
Land Resources
EN VIAONMENT At. OUALI T V
Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
PERMIT OWNER AFFILIATION DESIGNATION FORM
(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,
agency); f'�Cv �M
rCC pp � � 2��9 10✓
• the general partner or proprietor (for a partnership or sole proprietorship);
• or, the duly authorized representative of one of the above. [>ENR-LAND QUALITY
STORMNATERfAR( ITT G
1) Enter the permit number for which this change in Legally Responsible Individual ("Owner A i is ion
applies:
Individual Permit (or) Certificate of Coverage
N I C I S I I I I I N I C I G 1 12 10 0 5 6
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
Upper Piedmont Regional MSW Landfill
Republic Services of North Carolina, LLC
9650 Oxford Road
Address
Rougemont NC 27572
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
http://deg.nc. gov/about/divisions/energy-mineral-land-resources/energy-mineral-land-permits/stormwater-program
and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual:
Drew
First MI
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: Wade
Page I of 2
First MI
Isenhour
Last
Bailey
Last
S WU-OWNERAFFIL-23March201 7

NPDES Stormwater Permit OWNER AFRLATION DESIGNATION Form
(if no Facility Name/Ownership Change)
5) Reason for this change:
A result of.
If other please explain:
General Manager
Title
2001 Charles City Road
Mailing Address
Richmond VA 23231
City State Zip
( 804 ) 482-8337 [e-mail]
Telephone E-mail Address
r 804 1 785-2090
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 Wade Bailey , 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.
V&C'� r>k�
02/05/19
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
Page 2 of 2
S W U-O W NERAF F IL-23 Ma r2017