NCS000209_Owner Affiliation Change_20201027

Division of Energy,Mineral, and Land Resources FOR AGENCY USE ONLY
e Received
•
Land Quality Section/Stormwater Program ,� .,�
� � I!kY .1! D
- National Pollutant Discharge Elimination System (NPDES)
„etq .A i"H2i PERMIT OWNER AFFILIATION DESIGNATION FORM OCT � �
£
Ca»ri ne$tkisr�t s
(Individual Legally Responsible for Permit) DENR-LAND QUALITY
STORMWAI ER PERMITTING
Use this form there has been:
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 oi'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 C S Q 0 d 'a 0 Ct ; N C G1I
2) Facility-information:
Facility name: l a,nes na} or cc:j c. ares V.)rce C,nmpoy
Company/Owner Organization: 14a)tnes_ r�';c.tn2 •onalZrrc.
Facility address: 65c -E-30'an Rd-
Address
1-4ier_r)o(So V,kte C,
City State Zip
To find the current legally responsible person associated with your permit,go to this website:
baps://dey.nc.gov!about divisions/energy-mineral-land:J-esourcestencrg%-minerti-land-permits/npdes-industrial-
program and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: ` (:�(.p S Pad d 1(s
Hist Last j
4) NEW OWNER AFFILIATION(legally responsible for the permit):
;c S
Person legally responsible for this permit: SC,O L �i nk hAYY1
First btl Last
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S W U-O W NERAFru.-rNov2019

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownetship Change)
\ • p. Tube \rife TroduG.t S
Title
( 1 \.k si ark Ave.
Mailing Address
i ok�yip s q0W 1 1013
-7&5 -27/ `5-40 City l0/0)/7ez$State tt zip 1,
sfvilk hg wt9`-laresl nit tun-)
: Telephone E-mail Address II
( I )
Fax Number
5) Reason for this change:
A result of: [ Employee or management change
inappropriate or incorrect designation before
El Other
I,f other please explain:
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
I, S C o TT /.7/n!KNA ,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
Ii
l
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 http://deq.ne.goviaboutidivision 'en4- -mineral-land-resourcesistormwater
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