NCS000441_Owner Affiliation Change_20201104

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Division of Energy, Mineral, and Land Resources
FOR AGENCY USE ONLY
Land Quality Section/Stormwater ProgramDate Received
Year Month Day
- National Pollutant Discharge Elimination System (NPDES)
Energy,Mineral& PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resources
ENVIRONMENTAL°UAL,av (Individual Legally Responsible for Permit)
Use this form if 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 ChangeRpe F I V F D
and submit the completed form with all required documentation.
NOV 04 2020
What does "legally responsible individual"mean? DENR-LAND QUALITY
The person is either:
STORMWATER PERMITTING
• 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 C S 0 0 0 4 4 1 N C G
2) Facility Information:
Facility name: UNC-Chapel Hill -Small MS4
Company/Owner Organization: The University of North Carolina at Chapel Hill
Facility address: 1120 Estes Drive
Address
Chapel Hill NC 27599
City State Zip
To find the current legally responsible person associated with your permit,go to this website:
https://deq.nc.gov/about/divisions/energy-mineral-land-resources/energy-mineral-land-permits/npdes-industrial-
program and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Jonathan Pruitt
First MI Last
4) NEW OWNER AFFILIATION(legally responsible for the permit):
Person legally responsible for this permit: George E. Battle, III
First MI Last
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S WU-OWNERAF FIL4Nov20 19

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NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
Vice Chancellor for Institutional Integrity&Risk Management
Title
200 East Cameron Avenue,CB 1000
Mailing Address
Chapel Hill NC 27599-1000
City State Zip
( 919)445-1248 [e-mail]
Telephone E-mail Address
( )
Fax Number
5) Reason for this change:
A result of: IDEmployee or management change
CI 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, George E. Battle, III ,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.
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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: http://deq.nc.gov/about/divisions/energy-mineral-land-resources/stormwater
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