NCS000299_Owner Affiliation Change Form_20201202

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L0Md Reti ('.r5
Div i; on of Energy, Miaer4 and Land Rig soup�m
Land (fin m Litt' Section 1 Starmwater Jf" regra m
Nudonul P01JUT=1 D-kwharg-c El im inatirrin Sys= ('V } v-S)
PERMIT OWNER AFFILIATION DESIGNATION FORM
{Individual Legally RAMPOnsible for P rmit)
Use this form if there has been:
L7ime r.�;d
� }fnm oof
NO CHANGE in facility ownership or facility naMe, but the individual
who is Ie9alxy roe ponsible for the pennit has changed.
if the La- M& Of Vle fdcilitr has changed, -OF if fh& awnerahO of the facility has rhangl9dr
da NC)T arse 9his form- Instead, you most fill out a lti oma-owr er.5hip Change Form ,
and submit the comWated torrtf with a(l re-quired dacurvenfariaa.
What dam "legally regwm-.qi ble individ aal" mtan$
Thr pff54rl is eifl ew_
■ tfie resPunsi-ble eerPrate ofi;rer Ckw a c anon};
• the primilple cxccutivc officer sir ranking rJW4Ed official {fora numiciaity, sL Ec, fcdcral oroth,er puhfic
4. enckx
• the geaeraJ pamcr '?r PKPdekw (fur a fZart usEdp or soli rmil ricmrs5ipj'
or, the duly authrn izcd repmse-iWtive of ono ofihe above_
l) F-Weir the permf# number rGr wbieb this chaag-b in Txgally ftesponsihie indii AO Lral (` 0%mer A fli!iatio-n-)
applies:
Individual P&mit
�cIs I P
2b P:ad itg Informal-
Pacility name-
Cawnppny�Ow'ncr CNgail irxliUEti:
Pac1J3 ebs:
os Ceoil"Leatc zaf Carer of No Exposure
cJ f f i
C.-m_V f, Incunpera -1irkima Feelis
Caro lr!Q�te'j x
AdArm
NC 27
Zip
To find !hc curroilt kgaily respunsibm perms asso+cia[rd "31h VIM.F l)4un.d, Atr to this -Ixe Sim.
^4 ML!M I- I i nr_- r- } envrg,k -m in-:ra I-1aL1 j-jPyr-rrLw'-P n pdes-mdrl.c4ri.tl-
pro-rain and run #bC Permit Contact .4,ammar4 Riepart.
3) ql-,D 0"INNERAFFILTAInON that should be m7ruyved-
Pmvoous fegally rrsgrffl%TbLQ GndMdual= Jamb zoss
First ISE I.�kL
4) NEW OWNER AYR(.lATlt}IV (legally re.% nrmihie for the frrrmii):
PUSS legally MgMn5jbk fof illis pc�rrnit: Garin Atkin
I:ir%L mL LDS
SWI:, W%..kAFFIL4Nuv2QL4

NRDES Stop-nwater Permit OWNER AFFILIATION DESIGNATION
Form � if ne Faedity Name+ir'ucrship
5 i Reasao ffIr This change.
A rrsuJt of
r aher ldauc evir'rin:
I�p1+1 �QS L-�r
Title
1.5407 IVlCGOf Pmd Wag
Mailing Addre&c
_ Waal MBE 5?7
.F L-T'h4Me E-mail A
FAX Nufakr
Employe cr management e1 .U2t!
13 Tnap-prppriaw cw incOUCC[ dnagmwion beibm
(-)thcr
.....++...........+a...........+i�............ •++•..—.........+...............+r..............+.............
The cortifiication below MUSt be completed anil SiUned by the Permit hWder.
1'F'RMiTTEF CJI:R-IIF CA-f1()N:
Govin AtNrt5olrt , att -A ihat th is app] icon -cm fir tb-is Chanpc in Owner A M hat3pn
(Pe' 109AUY msPQMIWe for the Jxrmit) has bccn rcviewed and is 4=LMtc and complete Lo IIie hczst Of JMV
F,nowJo*, I ar► kn--"nd that Tali rpqujMd p of'this form are no# wmplAnd, tWr, e]ianRt msy r4Ut be
pmec,
-L42-
Si,paturc ]dale
P'ffF.ASE SEND TRIP COBVLF.TFI) FORM rrO-.
DEMT,R - Swrmwater N-oVarri
Dcpt_ ofEnv I=mcntaI "Jay
1612 Mail :w;m ice Ctatcr
Raleigh, Nurlh CwQlina 27694-1612
Fir mom informaiion or staff ixnwcvI, Pkam raft 19} 707-9M CFr visit the .►'ebsi7t,-
at: I I i ��::'rdOq_rrc_t��r;:ax��L'di� ii,�n; �•�•-f11 rtirnal-Iaod-resrf�eFcprimltl�r
�'jge 2 of 2
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