NCS000167_Owner Affiliaiton Change_20201229

Division of Energy, Mineral, and Land Resources rOR AOENCV USE ONLY
Quality Section / Stormwater Program ate
Received
Land
Q � g Year Month I Da
National Pollutant Discharge Elimination System (NPDES)
PERMIT OWNER AFFILIATION DESIGNATION FORM
(Individual Legally Responsible for Permit)
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.
If the name of the facility has changed, or ii the ownershia 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 Alliliation")
applies:
Individual Permit
nano
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
(or)
Perdue
Certificate of Coverage or No Exposure
N C G
LLC -Cofield
Perdue AgriBuslness, LLC
NCSR 1403
Address
Cofield NC 27922
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
hops://deg. nc.Qov/about/d ivisions/enerl;y-m inera I-land-resources/energy-mineral-land-perm program and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Wayne 1318ck
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
Susan A Murphy
Pirsl MI Last
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S WU-O\4NGIiAFPIL4Nov2019

NPDES Stormwater Permit OWNER AFFILIATION DESIONAI ION
Form (if no Facility Name/Ownership Change)
5) Reason for this change:
A result of:
/f other please expinrn:
Director, Environmental Services R Sustainability
Title
6906 Zion Church Road
Mailing Address
Salisbury MD 21804
City State Zip
( 443 ) 493-0786 [e-mail]
Telephone E-mail Address
Fnx Number
Employee or management change
❑ Inappropriate or incorrect designation before
❑ Other
...................................................................................................................
The certification below must be completed and signed by the permit holder.
PERM[TTEE CERTIFICATION:
1 Wayne Black ,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.
Signat a Date
PLEASE SEND THE COMPLETED FORM TO:
DEMLR - Sta•mwflter Program
Dept. of•Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 276994612
Por more information or staff contacts, please call [phone] or visit the website
at: http://deq.nc.t;ov/about/divisions/enert;v-mineral-land-resources/stormwater
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