HomeMy WebLinkAboutNCS000376_Owner Affiliation Change_2/10/2020Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
Ener-gy, Mineral PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resources
ENVIRONMENTAL 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 or No Exposure
N I C I 5 10 10 10 13 7 16 N I C I G
2) Facility Information:
Facility name: North Carolina State University
Company/Owner Organization: NC State University
Facility address: Campus Box 8007
Address
Raleigh NC 27695-8007
City State Zip
To find the current legally responsible person associated with your pennit, go to this website:
littps://deg.ne.gov/about/divisions/energy-mineral-land-resources/ener y-mineral-land-pennitshipdes-industrial-
program and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Scott Douglass
First MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: Charles Maimone
First MI Last
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NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
5) Reason for this change:
A result of:
If other please explain:
Vice Chancellor for Finance and Administration
Title
North Carolina State University, Campus Box 7201
Mailing Address
Raleigh NC 27695
City State Zip
(919 ) 515-2155 camaimon@ncsu.edu
Telephone E-mail Address
f 919 1 515-5121
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:
1, Charles Maimone , 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 (919) 707-9220 or visit the website
at: littp://deg.nc.gov/about/divisions/ener> -mineral-land-resources/stonnwater
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