NCS000321_Owner Affiliation Change_8/22/2019

Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
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PERMIT OWNER AFFILIATION DESIGNATION FORM
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(individual Legally Responsible for Permit)
Use this form if there has been:
FOR AGENCY USE ONLY
Date Received
Year
Month
I Day
NO h��l mcflHty owner�sft�p cw faidlity iimie, h�� it Will !1111� �i°idivldual
W�im liiis Ilfegally resjoonslHble For the 1mri-nit has chwiigedi,
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 I C I S 1U N I C I G
2) Facility Information:
Facility name:
.... .. .......... . . ........... ............... ... .. -- — -----------------
Company/Owner Organization:
Facility address: . .... Adsress
�J(
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: D
V1\e,5 �P� , 1` 1,4� � . . ........... . . . . . - - -- . - .1 N
First M1 Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
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F rs MI 'East
Pagel of
SWU-OWNERAFFIL-23March2017

NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
...
T�� `pqp�y
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V & p
Title
Mailing Address
f" city �ate )I� 0 ...:. ip Zip
o Lilly)
Telephone E-mail Add e' ss
..... .................. .......... _.........._....._......... _._
Fax 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, I, "a NV k4.. ° ,, 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.
Y
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: Cis c -land resources/stom.iwatcr
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SWU-OWNERAFFIL-23Mar2017