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HomeMy WebLinkAboutNCS000061_Owner Affiliation Change_20201112Division of Energy, Mineral, and Land Resources Land Quality Section / Stormwater Program National Pollutant Discharge Elimination System Energy, Mineral &PERMIT OWNER AFFILIATION DESIGNATION FORM Land ftia f` e' (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 legallywho is . for 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 (0r) Certificate of Coverage or No Exposure N I C I S 10 10 10 10 6 1 1N C I G 2) Facility Information: Facility name: Lenoir Mirror Co - Caldwell Site Company/Owner Organization: Lenoir Mirror Company Facility address: 401 Kincaid St. SW Address Lenoir NC 28645 City State Zip To find the current legally responsible person associated with your permit, go to this website: https://deg.nc. gov/about/divisions/energy-mineral-land-resources/energy-mineral-land-permits/npdes-industrial- ro am and run the Permit Contact Summary Report. 3) OLD OWNER AFFILIATION that should be removed: Previous legally responsible individual: Andrew M Mayberry First MI Last 4) NEW OWNER AFFILIATION (legally responsible for the permit): Person legally responsible for this permit: Darrell G Wilson First MI Last Page 1 of 2 S WU-OWNERAFFIL4Nov2019 NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION Form (if no Facility Name/Ownership Change) President/CEO Title PO Box 1650 Mailing Address Lenoir NC 28645 City State Zip (828 ) 728-3271 darrell@lenoirmirror.com Telephone E-mail Address t 828 ) 728-5010 Fax Number 5) Reason for this change: ❑✓ Employee or management change A result of: ❑ 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 Darrell G. Wilson , 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. cT 11/12/2020 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://deg.nc.gov/about/divisions/energy-mineral-land-resources/stonnwater Page 2 of 2 S WU-OWNERAFFIL-4Nov2019