NCG030392_Owner Affiliation Change_20210729 (2)

Energy, Mineral &
Land Resources
ENVIRONMENTAL OLIALIT Y
Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
PERMIT OWNER AFFILIATION DESIGNATION FORM
(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
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 (or) Certificate of Coverage or No Exposure
N I C I S N I C I G 0 3 0 3 9 2
2) Facility Information:
Facility name: Contech Engineered Solutions
Company/Owner Organization: Contech Engineered Solutions
Facility address: 6115 Chapel Hill Road
Address
Raleigh NC 27607
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-
rp ogram and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Dan L Moody
First M 1 Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit
Dan Sullivan
First MI Last
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S WU-OWNERAF FIL 1Nov2019

t
I NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
Plant Manager
Title
6115 Chapel Hill Road
Mailing Address
Raleigh NC 27607
City State Zip
(561 ) 2368894 [e-mail]
Telephone E-mail Address
Fax Number
5) Reason for this change:
A result of: 0 Employee or management change
Inappropriate or incorrect designation before
Other
If other please explain: Change of Mailing Address and Responsible Official
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
I, Dan Su iiGanLndthat
, attest that this application for this change in Owner Affiliation
,,Ian
gally rehe permit) has been reviewed and is accurate and complete to the best of my
knowle e. I undall required parts of this form are not completed, this change may not be
process
�l
l
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 [phone] or visit the website
at: http://deg.nc.gov/about/divisions/energy-mineral-land-resources/stormwater
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