NCG080786_Owner Affiliation Change_20190208

Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
K- ra National Pollutant Discharge Elimination System (NPDES)
Energy. Mineral& PERMIT OWNER AFFILIATION DESIGNATION FORM
land Resources
ENVIRONMENTAL OUALfTY (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, feREG&VLxCD
agency); FEB � � 2��� (?�Mg ✓
• the general partner or proprietor (for a partnership or sole proprietorship);
• or, the duly authorized representative of one of the above. �DENR-ALAND QUALITY
1) Enter the permit number for which this change in Legally Responsible Individual Y'T lia&l. �ING
applies:
Individual Permit
N I C I S
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
(or) Certificate of Coverage
N I C I G 0 18 0 7 8 6
GDS - Washington
Republic Services of North Carolina, LLC
450 Flanders Filter Rd
Address
Washington NC 27889
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
http://deq.nc.gov/about/divisions/enemy-mineral-land-resources/energy-mineral-land-permits/stormwater-pro - ram
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: Joseph
Page I of 2
First MI
Isenhour
Last
Dehner
Last
S WU-OWNERAFFIL-23March2017

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
5111 Chin Page Road
Durham
City
( 919 ) 433-0914
Telephone
(010 ) 991 1036
Fax Number
Title
Mailing Address
NC 27703
State Zip
[e-mail]
E-mail Address
r❑ Employee or management change
Q Inappropriate or incorrect designation before
❑ Other
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
I Joe Dehner , 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 requireoarts of this form are not completed, this change may not be
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 WU-OWNERAFFIL-23Mar2017