NCG050159_Owner Affiliation Change_20180619

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)
Energy, Mineral a. PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resources
ENVIRONMENTAL QUALITY (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 fill out a Name -Ownership Change Form
and submit the completed form with all required documentation.
What does "legally responsible individual" mean? RECPIV D
The person is either:
• the responsible corporate officer (for a corporation); J�f
• the principle executive officer or ranking elected official (for a municipality, sta�te?14eral or other public
agency); SroRENR.LA i%,D QUA, 17-Y
• the general partner or proprietor (for a partnership or sole proprietorslil ER P��114ITT1N(3
• 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 I C I S
2) Facility Information:
Facility name:
Company/Owner Organization
Facility address:
(or) Certificate of Coverage
N I C I G 10 15 10 11 5 9
Kroy Building Products (dBA: Ply Gem Fence and Rail)
15159 Andrew Jackson Hwy. Highway 76 West
Address
Fair Bluff NC 28439
City State /ip
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-perm its/stormwater-program
and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual:
Lannie
First
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit
S W1J-OWNERAFFIL-23March2017
McCoy
M1 Last
Anthony (Tony) G Rogowski
First M1 Last
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NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
Plant Manager
Title
15159 Andrew Jackson Highway 76 W
Mailing Address
Fair Bluff NC 28439
City State %ip
I b) Cad 9 'ESDIf�Tn1�, :r M. c;o m
Telephone E -mai Address S
Fax Number
5) Reason for this change:
A result of: 0✓ 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, Am"cft"4r�0601,44 , attest that this application for this change in Owner Affiliation
(person legall 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.
06/13/2018
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://deg.nc.gov/about/divisions/energy-mineral-land-resources/stormwater
Page 2 of 2
S W U-OWNERAFF Q.-23 Ma r2017