NCG120076_Owner Affiliation Change_7/26/2019

Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
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-land Resources PERMIT OWNER AFFILIATION DESIGNATION FORM
i;�n-NV�0NMFNTaLQV r, (individual Legally Responsible for Permit)
Use this form if there has been:
FOR AGENCY USE ONLY
Daze Received
Year
Montle
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 owner 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)
N C S
2) Facility Information:
Facility name: Surry County M
Company/Owner Organization: Surry County
Facility address: 237 Landfill Rd
Certificate of Coverage
N C G 1 2 0 0 7 6
I Solid Waste Landfill
Address
Mount Airy NC 27030
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
htt ://de .ne, ov/about/divisions/ener -mineral-land-resources/ener -mineral-land- ermits/storinwater- ro am
and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Dennis Bledsoe
First Mt Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit
Jessica Montgomery
First MI Last
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NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
Public Works Director
Title
237 Landfill Rd
Mailing .Address
Mount Airy NC 27030
City State Zip
( 336 ) 401-8380 [e-mail]
Telephone E-mail Address
(336 ) 401-8380
Pax Number
5) Reason for this change:
A result of ❑✓ Employee or management change
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, ttGl t0 , attest that this application for this change in Owner Affiliation
(person legally responsib e forth 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.
Si ature 0 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: h ://de .nc. av/about/divisions/enerq -mineral-land-resources/stortnwater
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S WU-OWNU RAFFIL23Mar2()17