NCS000130_Permit Owner Affiliation Designation Form_20191023.PDF

Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
nco,g `° Mirwrat & PERMIT OWNER AFFILIATION DESIGNATION FORM
L ami 'E +1orce?:
FOR AGENCY USE ONLY
Date Received
Year
Month
Day
RE-0,17R/F0
Use this form if there has been: DENS-LAXIa QUALITY
STORt�iU l/,, . , `'" t11lT i"itVf
NO CHANGE in facility ownership or facility name, but the indlvldu'af
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 I C I S 10 0 10 11 1 1N I C I G
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
Perdue Farms, LLC-Rockingham
Perdue Farms, LLC
416 South Long Drive
Address
Rockingham NC 28379
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
http:Hdeq.iic.gov/about/divisions/energy-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:
Kendall
Casey
First MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: David L Hiner
First MI Last
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S WU-OWNERAFFILr23March2017

NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
5) Reason for this change:
A result of:
If other please explain:
Director of Operations
416 South Long Drive
Title
Rockingham
Mailing Address
NC 28379
City
( 910 ) 997-8541
State Zip
[e-mail]
Telephone
E-mail Address
( )
Fax Number
❑✓ Employee or management change
Inappropriate or incorrect designation before
❑ Other
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
I D. Lee Hiner , 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 Iny
knowledge. I understand that if all required parts of this form are not completed, this change may not be
processed.
1� - F."
k
ig
ure
10/11/2019
PLEASE SEND THE COMPLETED FORM TO:
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
Date
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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S W U-O W NERAFF Il,23 Mar2017