NCG030139_Owner Affiliation Change_20210521

Division of Energy, Mineral, and Land Resources 1 FOR AGENCY USEONLY
Land Quality Section / Stormwater Program I Y— I M h I o,
Nadonal Pollutant Discharge Elimination System (NPDES)
Energy,Mineral3 PERMIT OWNER AFFILIATION DESIGNATION FORM
LandResources
sMn *d4FHTALQU unY (Individual Legally Responsible for Permit) .
Use this form if there has been:
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 All 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
INICISI I I I I I INIcIrlo 13 jo 11 13E
2) Facility Information:
Facility name. Mueller Systems
Company/Owner Organization: Mueller Company
Facility address: 10210 Statesville Blvd.
Address
Cleveland NC 28673
city state zip
To find the current legally responsible person associated with your permit, go to this websile:
hitns:/Idcn.nc.gov/about/dMsions/encruy-mineral-land-resources/cneray-mineral-land-penniLs/npdes-industrial-
protnam and tut the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Steven Holz-meister
First M1 Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
John Small
First M1 Last
Page 1 of 2
5 W11-O WNERAFFa.4Nov2019

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
EHS Manager
Title
PO Box 128
Mailing Address
Cleveland NC 27013
City state zip
(704 )278-5334 [e-mail]
Telephone E-mail Address
Fax Number
5) Reason for this change:
A result of El Employee or management change
0 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 John Small , 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. 1 understand that if al required parts of this form are not completed, this change may not be
processed.
05/2112021
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://dcq.nc.gov/about/divisionslcnergy-mineral-land-resources/storrnwater
Page 2 of 2
s WV-pWN9RAFF0,-4Nov2a19