NCG130058_Owner Affiliation Change_20190208

Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
Energy. Mineral & PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resources
ENVIRONMENTAL. QUALITY (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); R (� 1
• the principle executive officer or ranking elected official (for a municipality, statee erg or othe a is
agency); FEB 0 8 2019 �,,vts ✓
• the general partner or proprietor (for a partnership or sole proprietorship);
• or, the duty authorized representative of one of the above. DENR-LAND QUALITY
STORMWATER PERMITTING
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 S N I C I G 11 13 10 0 5 8
2) Facility Information:
Facility name: Raleigh Transfer Station
Company/Owner Organization: Republic Services of North Carolina, LLC
Facility address: 5565 Thornton Road
Address
Raleigh NC 27616
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
http://deq.nc.gov/about/divisions/energy-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 Isenhour
First MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: Joseph Dehner
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
5111 Chin Page Road
Mailing Address
Durham NC 27703
City State Zip
( 919 ) 433-0914 [e-mail]
Telephone E-mail Address
(919 ) 991-1036
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 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 required parts of this form are not completed, this change may not be
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
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S WU-OWNERAFFIL-23Mar2017