NCG050174_Owner Affiliation Change_20190923

EL 34-ft Division of Energy, Mineral, and Land Resources
Use this form if there has been:
FOR AGENCY USE ONLY
Bate Received
Year
I Month
I Bay
s •r �: r.
s is legallyresponsible r 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 (o3) Certificate of Coverage
N C: I :S, N I C. I G 0 15 0 11 1 7
2) Facility Information:
Facility name: Georgia-Pacific Corrugated LLC
Company/Owner Organization: Georgia-Pacific Corrugated LLC
Facility address: 200 McDowell Rd
Address
Asheboro NC 27203
City State zip
To find the current legally responsible person associated with your permit, go to this website:
http://deg.no,goy/about/d ivisions/energy-mineral-land-resources/eiiergy-mineral-land-permits/stonnwater-p_ogram
and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Charles E Wells
Fist MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: Ronald E Cannon
First MI Last
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NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
Director of Operations
Title
200 McDowell Rd
Mailing Address
Asheboro NC 27203
City state Zip
( 336 ) 318-1339 rona[[e-mail]
Telephone E-mail Address
f 336 1 626-0917
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, Ronald E. Cannon , 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 charge may not be
process
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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