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HomeMy WebLinkAboutNCG070175_Owner Affiliation Change_20240610 Division of Energy,Mineral,and Land Resources FOR AGENCY USE ONLY Date Received Land Quality Section/Stormwater Program Year Month Day National Pollutant Discharge Elimination System(NPDES) PERMIT OWNER AFFILIATION DESIGNATION FORM (Individual Legally Responsible for Permit) Use this form if there has been: * CH . - in facility o ners i or facility e, but the in.ividual ho is le.ally res3onsi•le for the permit has chanted„ 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 NCS N C G0701 75 2) Facility Information: Facility name: Gold Bond Building Products-Mount Holly Plant Company/Owner Organization: Gold Bond Building Products LLC Facility address: 1725 Drywall Drive Address Mount Holly NC 28120 City State Zip To find the current legally responsible person associated with your permit,go to this website: fez,-Lz: 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: Lance Davis First MI Last 4) NEW OWNER AFFILIATION(legally responsible for the permit): Person legally responsible for this permit: Todd D Broud First MI Last Page 1 of 2 Last revised 20 Feb 2022 NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION Form (if no Facility Name/Ownership Change) VP-Manufacturing Operations&Engineering Title 2001 Rexford Road Mailing Address Charlotte NC 28211 City State Zip (704 ) 365-7691 toddb@nationalgypsum.com Telephone E-mail Address ( ) Fax Number 5) Reason for this change: A result of: l2 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. t : 40 CF ( ) requires art otiosinai signature (not di.itaI) PERMITTEE CERTIFICATION: I, Todd D Broud ,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. ev(4,—/iP, 4/1 L.4.4 Signature Date PLEASE SEND THE ORIGINAL SIGNED COPY OF IRE 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:htp: ;d ,jc ;o% s . 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