NCG050153_Owner Affiliation Change_20210308

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
Lund Resource:
FNVIRONb1t rNfAL QULt.m, (Individual Legally Responsible for Permit)
FOR AGENCY USE ONLY
Date Received
Year
Month
I Day
Use this form if there has been:
NO CHANGE in facility ownership or facility name, but the indivdua)
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 C S
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
(or) Certificate of Coverage or No Exposure
N I C I G O 5 10 11 1.5
Cascades Tissue Group -Rockingham
Cascades Tissue Group -North Carolina, a division of Cascades Holding US Inc.
805 Midway Rd.
Address
Rockingham North Car( 28379-4101
City state zip
To find the current legally responsible person associated with your permit, go to this website:
littps:Hdeg.tic.gov/about/divisions/energy-mineral-land-resources/energy-mineral-land-permits/npdes industrial
rogram and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: John
First MI
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
Quick
Last
Corey Wyand
First MI Last
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NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
5) Reason for this change:
A result of. -
If other please explain:
Jean-Francious Merette V.P. Operations
Title
PO Box 578 805 Midway Rd.
Mailing Address
Rockingham North 1 28380
City State Zip
(514 ) 249-0784 jean-Francios Merette
Telephone E-mail Address
t 910 1895-9887
Fax Number
El Employee or management change
❑ Inappropriate or incorrect designation before
❑ Other
...............................................................................................................
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
I Jean-Francious Merette , 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.
02-12-2021
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 infonnation 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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