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HomeMy WebLinkAboutNCS000423_Concord Owner Affiliation Designation Form_20201105 Division of Energy,Mineral, and Land Resources FOR AGENCY USE ONLY Land Quality Section/Stormwater Program Y� DeT ""°ea r4JE " IVED National Pollutant Discharge Elimination System (NPDES) Nov o 5 2020 Energy.Mineral& PERMIT OWNER AFFILIATION DESIGNATION FORM Land Resources ENVIRONMENT Al QUALITY (Individual Legally Responsible for Permit) Dr NR-LAND QUALITY MWATER PE MITTING 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.RECEIVE If the name of the facility has changed, or if the ownership of the facility has 449VOcb 2029 do NOT use this form. Instead,you must fill out a Name-Ownership Change Form and submit the completed form with all required documentation. DENR-LAND QUALI STORMWATER PERMIT (Nr= 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 C S 0 0 0 4 2 3 N C G 2) Facility Information: Facility name: Concord City-Small MS4 Company/Owner Organization: Facility address: 35 Cabarrus Ave W Address Concord NC 28025 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-perm its/npdes-industrial- program and run the Permit Contact Summary Report. 3) OLD OWNER AFFILIATION that should be removed: Previous legally responsible individual: Brian W. Hiatt First MI Last 4) NEW OWNER AFFILIATION(legally responsible for the permit): Person legally responsible for this permit: Lloyd Wm. Payne First MI Last Page 1 of 2 S WU-O WNERAFFIL4Nov2019 NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION Form (if no Facility Name/Ownership Change) City Manager Title PO Box 308 Mailing Address Concord NC 28026-0308 City State Zip (704 ) 920-5209 paynel@concordnc.gov Telephone E-mail Address (704 )795-0404 Fax Number 5) Reason for this change: A result of: 0✓ 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: 1, Lloyd Wm. Payne , ,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. SiCI ,74 .001111/ ' 1/07/frg/1-‘ a9-% alOol-0 :, ature 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 Page 2 of 2 S WU-OWNERAFFIL-4Nov2019