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HomeMy WebLinkAboutNCG130019_Owner Affiliation Change_20220512D E Q!' Division of Energy, Mineral, and Land Resources NORTH CAROLINA DeparlmeirtofEmironmeirtalQuality 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 N I C I S 2) Facility Information: Facility name: Company/Owner Organization Facility address: (or) Certificate of Coverage or No Exposure N I C I G 1 3 0 0 1 9 8tMb"'6A lgtelj ftr(ft�ham) StWb*6AlVledel!Jft Inc 5CEBjckcflc bad Address Durham NC 27713 City State Zip To find the current legally responsible person associated with your permit, go to this website: https://deg.nc.gov/sw/ Navigate to the "NPDES Industrial Program" section and run the Stormwater Permit Contact Summary Report for your permit number. 3) OLD OWNER AFFILIATION that should be removed: Previous legally responsible individual: Dell Golanski First MI Last 4) NEW OWNER AFFILIATION (legally responsible for the permit): Person legally responsible for this permit: Zachary Aucker First MI Last Pagel of 2 Last revised 20 Feb 2022 NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION Form (if no Facility Name/Ownership Change) ErW�wniwevitOb®p�api�aMee*lanager Title 1856 Old Berick Road Mailing Address Bloomsburg PA 17815 City State Zip (570 )238-5232 Telephone E-mail Address ( ) Fax Number 5) 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. Note: 40 CFR 122.22(c) requires an original & , re (not digital) PERMITTEE CERTIFICATION: I, Za&mnA ker , 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. 056MM022 Signature Date PLEASE SEND THE ORIGINAL SIGNED COPY OF THE COMPLETED OWNER AFFILIATION CHANGE 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 (919) 707-9220 or visit the website at: http://deg.nc.gov/sw Per NC General Statute 143-215.6B (i), any person who knowingly makes any false statement, representation, or certification in any application, record, report, plan, or other document filed or required to be maintained under this Article or a rule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may include a fine not to exceed ten thousand dollars ($10,000). Page 2 of 2 Last revised 20 Feb 2022