NCS000453_Email re Owner Affiliation update_20201021

McCoy, Suzanne
From: Todd Huntsinger <[e-mail]>
Sent: Wednesday, October 21, 2020 9:20 AM
To: McCoy, Suzanne
Cc: Kathy Queen
Subject: [External] Owner Designation Affiliation Form (Town of Indian Trail) - Executed
Attachments: OwnerDesignationAffiliationForm_IndianTrail.pdf
Follow Up Flag: Follow up
Flag Status: Completed
External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
report..p nc.gov
Suzanne,
Please see attached executed document.
Let me know if you have questions.
Sincerely,
Todd Huntsinger
Director of Engineering
Town of Indian Trail
315 Matthews -Indian Trail Road
r
PO Box 2430
Indian Trail, NC 28079
Office 704-821-5401
--'
Fax [phone]
Email [e-mail]
Visit us at www.indiantrail.or-
Pursuant to North Carolina General Statutes Chapter 132, Public Records, this electronic mail message and any
attachments hereto, as well as any electronic mail message(s) that may be sent in response to it may be considered
public record and as such are subject to request and review.
1

Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
Energy. Mineral & PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resources
ENVIRONMENTAL OUALITY (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
N I C I S I p -c:::,Lq 53
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
(or) Certificate of Coverage or No Exposure
N C G
<1�1.L
`7 DW/V ��bIOA, -7-1Z,4_TT-t✓
Address
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City State Zip
To find the current legally responsible person associated with your permit, go to this website:
https:Hdeg . nc. gov/about/divisions/energy-mineral-land-resources/energy-m ineral-land-permits/npdes-indlistrial-
ro ram and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: E_/)k1/,gj26 G i�
First MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: —�� � � W-6 � 4g�Z
First MI Last
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S WU-0WNERAFFIL4Nov2019

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
oz
Title
Mailing Address
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City State Zip
Telephone E-mail Address curl
Fax Number
5) Reason for this change:
A result of: 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:
I, ,Q-fl/A-(U' , attest that this application for this change in Owner Affiliation
(person legally responsible i`or 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.
nature Date
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PLEASE SEND THE COMPLETED FORM TO:
�: ' ••'• �'
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DEMLR - Stormwater Program
g
: ;OFFICIAL
=�• SEAL
Dept. of Environmental Quality
1612 Mail Service Center
'�, �y�''•• •'�•�,o ��
Raleigh, North Carolina 27699-1612
�:'09PORAl��`,��'�
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 WU-0WNERAFFIL-4Nov2019