NCG0120060_Owner-Affiliation-Change-Foothills 2018.pdf

Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
K, I Iry National Pollutant Discharge Elimination System (NPDES)
Energy, Mineral & PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resources
EWRONMENTAL 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);
• 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 (or) Certificate of Coverage
N C S N C G 1 2 0 1 0 6 0
2) Facility Information:
Facility name: Foothills Environmental Landfill
Company/Owner Organization: Republic Services of North Carolina, LLC
Facility address: 2800 Cheraw Rd.
Address
Lenoir NC 28645
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
http://deq.nc. gov/about/divisions/ener�zy-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 Isenhour
First Nil Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: Gary S Walker
First MI Last
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S WU-OWNERAFFIL-23March2017

NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
Vice President
Title
2440 Whitehall Park Drive
Mailing Address
Charlotte NC 28273
City State Zip
980 ) 430-8511 [e-mail]
Telephone E-mail Address
(980 ) 430-8495
Fax Number
5) Reason for this change:
A result of: Employee or management change
® Inappropriate or incorrect designation before
Ej Other
If other please explain:
The certification below must be completed and signed by the permit holder.
191170VI101Dl Wall1171Y1y[f1:VY[130
1, Shane Walker , 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.
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
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