NCG070099_Owner (Affiliation Change)_20191007

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
Land Resources
ENVIRONMENTAL QUALITY (Individual Legally Responsible for Permit)
Use this form if there has been:
FOR AGENCY USE ONLY
Date Received
Year
Month
Da
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? R P C F I VE D
The person is either: OCT 07 2019
• the responsible corporate officer (for a corporation);
• the principle executive officer or ranking elected official (for a municipality, stag W l& Tli'ublic
agency); STORMIAIAT=R PE-RUTI-ING
• 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 IC IS
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
(or) Certificate of Coverage
N I C I G 0 1 7 1 0 1 0 9 9
Ardagh Glass Inc.
Ardaah Glass Inc.
2201 Firestone Parkway
Address
Wilson NC 27893
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
hiip://deg.nc.gov/about/divisions/energy-m ineral-land-resources/energy-m ineral-land-permits/stonnwater-program
and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Christopher A Say
First MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit
Brian Jaggernauth
First Ml Last
SWU-OWN E RAFFI L-23M arch2017
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NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
Plant Manager
Title
2201 Firestone
Mailing Address
Wilson NC 27893
City State Zip
Bri an. j aggemauth@ardaghgro up
[phone] corn
Telephone E-mail Address
[phone]
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:
I, Brian jaggernauth, 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 require parts of this form are not completed, this change may not be processed.
jtl� �f 11*11 'r'r"� � / 010 z1 Aa / y
Signature Date
PLEASE SEND THE COMPLETED FORM TO:
Division of Energy, Mineral, and Land Resources
Stormwater Program
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
For more information or staff contacts, please call [phone] or visit the website at:
http://deq.nc. gov/about/divisions/energy-mineral-land-resources/storrnwater
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SWU-OWNERAFFIL-23Ma2017