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HomeMy WebLinkAboutNCS000369_Owner Affiliation Change_20201125Division of Energy, Mineral, and Land Resources Land Quality Section / Stormwater Program National Pollutant Discharge Elimination System (NPDES) Energy,Minerallk PERMIT OWNER AFFILIATION DESIGNATION FORM Lm�dRNIAA WLGAMY (individual Legally Responsible for Permit) Use this form if there has been: FOR AGENCY USE ONLY Dnic Received Yenr Month Uny 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 (v?) Certificate of Coverage or No Exposure N I C S 0 10 10 13 16 9 1 INICIGI 2) Facility Information: Facility name: Company/Owner Organization Facility address: Buller -Warner Generation Plant Fayetteville Public Works commission 2274 Custer Avenue Address Fayetteville NC 28312 City State zip To find the current legally responsible person associated with your permit, go to this website: htt s://de .ne. ov/about/divisions/encr -mineral-land-resources/ever -mineral-land- ermits/n des-industrial- ro ram and run the Permit Contact Summary Report. 3) OLD OWNER AFFILIATION that should be removed. - Previous legally responsible individual: Mallon First Ml 4) NEW OWNER AFFILIATION (legally responsible for the permit): Person legally responsible for this permit: William C rust Ml Page t of 2 Noland Last May Last S W U-O W NE It AF F lL4Nov20l9 NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION Form (if no Fneility Name/Ownership Change) Power Plant Manager Title PO Box 1089 Mailing Address Fayetteville NC 28302-1089 City Slate Zip ( 910 ) 223-4814 ace.may@faypwe.com Telephone F-mail Address Fax Number S) 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. PERMITTEC CERTIFICATION: I, �sV0- �% + ` r ' d , attest that this application for this change its Owner Affiliation (person legally responsible for the permit) has been reviewed and is accurate and complete to the hest of my knowledge. 1 understand that if all required parts of this form are not completed, this change may not be processed. "-D �^ Sign re Date PLEASE SEND THE COMPLETED FORM TO: DEMLR - Storinwater 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://deci.nc.gov/about/divisions/energy-mineral-land-resources/stormwater Page 2 of 2 8 wU-O wNEiRAF FIIANov20t9