NCG190050_Affiliation Change_20181130

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NCDENR
NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT AND NATURAL RE50URCE5
Division of Energy, Mineral and Land Resources
Land Quality Section / Stormwater Permitting Program
National Pollutant Discharge Elimination System (NPDES)
PERMIT OWNER AFFILIATION DESIGNATION FORM
(individual Legally Responsible for Permit)
FOR AGENCY USE ONLY
Date Received
Year
Month
Day
RFr,F:!\/FD
NOV 30 2018
Use this form if there has been: DES R-E_AND QUALITY
STORM''VVATER PCERN41TTING
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, 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 I C I S
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
(or) Certificate of Coverage
N I C I G 1 11 91 01 01 51 0
USCG SFO FT MACON
United States Coast Gurad
2301 East Ft. Macon Rd.
Address
Atlantic Beach NC 28512
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
http://portal.ncdenr.orWweb/lr/sw-permit-contacts and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Javier A. Delgado
First MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: George O. Fulenwider
First MI Last
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SWU-OWNERAFFIL-25July2014

NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
USCG SFO Ft. Macon Logistics Department Head
Title
2301 East Ft. Macon Rd.
Mailing Address
Atlantic Beach NC 28512
City State Zip
( 252 ) 240-8450 [e-mail]
Telephone E-mail Address
( 252 ) 240-5460
Fax Number
5) Reason for this change:
❑x Employee or management change
A result of: ❑ Inappropriate or incorrect designation before
❑ Other
If other please explain:
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
I, 6zw",-�` • rr L4_,A6,11_ Ee , 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.
Signa ure Date
PLEASE SEND THE COMPLETED FORM TO:
Division of Energy, Mineral and Land Resources
Stormwater Permitting Program
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
For more information or staff contacts, please call 919-707-9220 or visit the website at:
http://portal.ncdenr.or,g/web/lr/stormwater
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SWU-OWNERAFFIL-25July2014