NCG060161_Owner Affiliation Change Request_20220105

Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
K, "Iry National Pollutant Discharge Elimination System (NPDES)
Energy, Miners! & 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
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 C S N C G 0 6 0 11 6 1
2) Facility Information:
Facility name: Clement Pappas Plant
Company/Owner Organization: Clement Pappas NC,LLC
Facility address: 125 Industrial Park Rd
Address
Hendersonville NC 28792
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
https:Hdeg.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: Wade Anderson
First Nit Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: Blake M Kehoe
First MI Last
Page 1 of 2
S WU-OWNERAFFJ1ANov2019

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
Director of Engineering
Title
125 Industrial Park Rd
Mailing Address
Hendersonville NC 28792
City State Zip
(828 )243-9572 [e-mail]
-Telephone E-mail Address
(828 )693-8154
Fax Nu nlx:r
5) Reason for this change:
A result of; El Employee or management change
11 Inappropriate or incorrect designation before
❑ Other
If aiher please explain:
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
I,{?E I(44`4/ I/241&-- ,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
knowled . derstand that if all required parts of this form are not completed,this change may not be
proe
5 2oz
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(919)707-9220 or visit the website
at:http:t/deq.nc_govlabotltldivisionslenergy-mineral-land-resourceslstormwater
Page 2 of 2
s WU-ownrERA}Fll 4Nov2ot9

Georgoulias, Bethany
From: Kehoe Blake <[e-mail]>
Sent: Wednesday, January 5, 2022 9:55 AM
To: Georgoulias, Bethany
Cc: Wolfe Dale
Subject: RE: [External] Stormwater Signature Authority
Attachments: Clement Pappas Owner Affilation Form 1-5-22.pdf
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
Bethany,
Please see attached. Both Wade and Billy have left the company.
Greg Mangione the person signing this is the VP of Manufacturing for the company.
Let me know if I need to fill out any other forms.
Thanks for the help.
Blake Kehoe
Director, Engineering
LASSONDE I Lassonde Pappas and Company, Inc.
[e-mail]
125 Industrial Park Road, Hendersonville, NC, 28792
T [phone] ,1707
C [phone]
Visit us @ Lassonde Pappas I Apple & Eve I Old Orchard
This message is intended only for the named recipients. This message
may contain information that is privileged, confidential or exempt from
disclosure under applicable law. Any dissemination or copying of this
message by anyone other than a named recipient is strictly prohibited. If
you are not a named recipient or an employee or agent responsible for
delivering this message to a named recipient, please notify us immediately,
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From: Georgoulias, Bethany <[e-mail]>
Sent: Wednesday, December 29, 2021 8:49 AM
To: Kehoe Blake <[e-mail]>
Cc: Wolfe Dale <[e-mail]>
Subject: RE: [External] Stormwater Signature Authority
Blake,

I believe the Owner Affiliation is supposed to fill this form out to grant signature authority to you — you can't fill it out to
grant it to yourself. In our system right now, that person is Wade Anderson. Is that still correct, or has it changed?
Related Permits
E Waiver
Outfall
Comments
History
Inspections
Incidents
Enforcements
Violations
Details 1
Details 2
Billing
Class.lDesig.
Events
Reg. Activities
Eff. Guidelines
Affiliati1
Permit: NCGO60161 Version: 8.0
Status: ktive
Entity
*Affiliation Type
Name
Title
Phone Number
Owner
Owner
Anderson. Wade
Plant Manager
[phone]
Permit
Billing
'Xatson, Billy
[phone] Ext.125
Permit
Contact Person
[phone]
If that is not correct, the company needs to fill out the attached Owner Affiliation Change Form for to make an update to
the legally responsible person (Owner Affiliation). You can email a scanned copy of that form back to me, and I will make
the updates when I return to the office next week. I recommend reviewing the attached report to see if all other
contacts are accurate.
Here is the info from the top of the form that I am referring to. You have identified yourself as the Responsible Official
in Part B, but it appears to be someone else right now. If an update is necessary and you are the current responsible
official, you won't need to delegate authority to yourself. However, if anyone else will be authorized to submit reports,
you'll need to delegate signature authority to them. On the other hand, if Wade Anderson is still the Responsible
Official, then he needs to fill out Part B of this form so he can delegate signature authority to you.
Corm prat r Permit Delegation of Signature Authority Form
Dired ons are 6 red.
This dorm shall he used to delegate signahrre guff )rrty from f h @ permit Own or (Permilt ) to
another party, Only the Resppnsible Official defined below may subn f permit applications and
reports required by the perrWt (such as Data Maniforing Rep offs and Annual Reports) until this
form is coinpleted and sub (ni fed to the DE41LR Stormwater Program. Please role chat delegafingr
signature authority does riot relieve the Permit Owner from the responsibility for permit
compliance,
I hope this makes sense.
Thanks,
Bethany Georgoulias (she/her)
Environmental Engineer
Stormwater Program, Division of Energy, Mineral, and Land Resources
N.C. Department of Environmental Quality
919 707 3641 office
[e-mail]
512 N. Salisbury Street, Raleigh, NC 27604 (location)
1612 Mail Service Center, Raleigh, NC 27699-1612 (mailing)
Website: http://deq.nc.gov/about/divisions/energy-mineral-land-resources/stormwater

Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties
Based on the current guidance to minimize the spread of COVID-19, the Department of Environmental Quality has
adjusted operations to protect the health and safety of the staff and public. Many employees are working remotely or
are on staggered shifts. To accommodate these staffing changes, all DEQ office locations are limiting public access to
appointments only. Please check with the appropriate staff before visiting our offices, as we may be able to handle your
requests by phone or email. We appreciate your patience as we continue to serve the public during this challenging
time.
From: Kehoe Blake [mailto:[e-mail]]
Sent: Tuesday, December 28, 2021 1:36 PM
To: Georgoulias, Bethany<[e-mail]>
Cc: Wolfe Dale <[e-mail]>
Subject: [External] Stormwater Signature Authority
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
Bethany,
Please see attached.
Let me know if you need anything else.
Thanks
Blake Kehoe
Director, Engineering
LASSONDE I Lassonde Pappas and Company, Inc.
[e-mail]
125 Industrial Park Road, Hendersonville, NC, 28792
T [phone] ,1707
C [phone]
Visit us @ Lassonde Pappas I Apple & Eve I Old Orchard
This message is intended only for the named recipients. This message
may contain information that is privileged, confidential or exempt from
disclosure under applicable law. Any dissemination or copying of this
message by anyone other than a named recipient is strictly prohibited. If
you are not a named recipient or an employee or agent responsible for
delivering this message to a named recipient, please notify us immediately,
and permanently destroy this message and any copies you may have.
Warning: Email may not be secure unless properly encrypted.