NCS000347_Owner Affiliation Form_20180802

Energy. Mineral &
Land Resources
ENVIRONMENTAL QUALITY
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
YearMonth Day
ElVEFD
AUG 02 ?018
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
N I C I S 10 10 10 13 1 N I C I G
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
o
CPI USA North Carolina - Roxboro Plant
CPI USA North Carolina LLC
331 Allie Clay Road
Address
Roxboro NC 27573
e City State Zip
To find the current legally responsible person associated with your permit, go to this website:
http://deg nc.gov/about/divisions/energy-mineral-land-resources/energy-mineral-land-permits/stormwater-program
and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Frank
First
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: Terry
S W U-OWNERAFF LLr23Nbrch2017
Hayward
MI Last
Nealy
First MI Last
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NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
Plant Manager
l itlr
331 Allie Clay Road
Roxboro
Mailing Address
NC 27573
City State Zip
[phone] -tns %%kA)W;Aa1 ,poure.v • c.aw,
Telephone E-mailAddress
(33h) 330-*Pq
Fax Number
5) Reason for this change:
A result of: Employee or management change
❑ Inappropriate or incorrect designation before
❑ Other
If other please explain:
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
1, Terry Nealy , 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.
SignaturQs 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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S WU-OWNERAFFH,23Mar2017