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Home My WebLink AboutNCG170420_COMPLETE FILE - HISTORICAL_20110820- - STORMWATER-DIVISION CODING SHEET RESCISSIONS. PERMIT NO. DOC TYPE 19-eOMPLETE FILE - HISTORICAL DATE OF RESCISSION ❑ YYYYMMDD NC®ENR Division of Energy, Mineral and Land Resources Land Quality Section / Stormwater Permitting Program National Pollutant Discharge Elimination System (NPDES) PERMIT OWNER AFFILIATION DESIGNATION FORM (Individual Legally Responsible for Permit) Use this form if there has been: FOR AGENCY USE ONLY Date Received Year I Month I 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: RECEIVED ED • the responsible corporate officer (for a corporation); • the principle executive officer or ranking elected official (for a municipality, st4gIP401 ZoVther public agency); • the general partner or proprietor (for a partnership or sole proprietorship); DENR-LAND QUALITY • or, the duly authorized representative of one of the above. STORMWATER PERMITTING 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/ O 9 2 0 14Vee`/ 0jF/.11IS0,V- RSIS Av69Y I06N.y/5aV 950 GeRtnR.V ST Address %,volR Nk- 2864.s- City State Zip To find the current legally responsible person associated with your permit, go to this website: httl):Hportal ncdenr.orWNweb/Ir/sw-permitcontacts and run the Permit Contact Summary Report. 3) OLD OWNER AFFILIATION that should be removed: Previous legally responsible individual:-CFFER`( SUTTLES First MI Last 4) NEW OWNER AFFILIATION (legally responsible for the permit): Person legally responsible for this permit: C>HN K. 1 UiwEg First MI Last Page 1 of SW U-OW NERAFFIL-25July2014 NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form (if no Facility Name/Ownership Change) PL.f}N-f CStTE, %14A.t/^ci� Title 95-D GkFIZMAN S�' Mailing Address teA10 R AIC 2844s City State Zip (928) r759- 3430 John Avrn�i ttA ayu Jenni50n .cAat Telephone E-mail Address (82e) t758 - 2038 Fax Number 5) Reason for this change: A result of: LI 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: 1, �1w TVKNFk 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. ignature Y-15-1'( PLEASE SEND THE COMPLETED FORM TO: Division of Energy, Mineral and Land Resources Stormwater Permitting Program 1612 Mail Service Center Raleigh, North Carolina 27699-1612 Date For more information or staff contacts, please call 919-707-9220 or visit the website at: hM:Hportal.ncdenr.org/web/Ir/stonnwater Page 2 of 2 SW U-OW NERAFFIL-25July2014 NC Division of Energy, Mineral and Land Resources NPDES Stormwater Permit Contacts Summary NC DENILR has the folloe ine contact information in our Permit Database for your permit as of 811212014. Permit Number: NCG170420 Permit Type: Textile Mill Products Stormwater Discharge COC Facility Name: Avery Dennison Facility Addressl: 950 German 5[ Facility Address2: City, State & Zip: Lenoir NC 28645 Owner Information Details: Owner Name: Owner Type: MUST submit a Change of Name/Ownership form to DEMLR to make any changes to this Owner information. See "Miscellaneous Forms" at htto•//portal ncdemr org/web/Ir/nodes-stormwater Avery Dennison Non -Government Owner Type Group: Organization *** Legally Responsible for Permit *** (Responsible corporate officer/principle executive officer or ranking elected official/general partner or proprietor, or any other person with delegated signatory authority from the legally responsible person.) Owner Affiliation: Jo i1n IV�rI� Title: P tct0't ` SI�:L� %• wr,t4q,e�• Addressl: 950 German St �/ Address2: City, State & Zip: Lenoir, NC 28645 Work Phone: gZ.8-75-9- 34310 Fax: S216-%SS- 263S Email Address: jph {� r tVrgL P Qcrvu'j7 dlil/1 ( Su/( CONS Owner Contact Person(s) Contact Name Title Address Phone Fax Emai Birin Patel EHS Manager 2025 16th St, Greensboro, NC 27405 336-808-7296 birin.patel@averyden Facility Contact Person(s) Contact Name UU2 Address Phone fib Email Botk_{over- tN5 SPeu4 Ii6'E 950 German St, Lenoir, NC 28645 828-759-14411 lteth.curey@averyde add Nr� 3450 nnison.com Permit Contact Person(s) Contact Name Title Address phone Eaais Email Birin Patel EHS Manager 2025 16th St, Greensboro, NC 27405 336-808-7296 blrin.patel@averyden _Permit Billing Contact Contact Name Title Address Phone Fax Email Biren Patel 2025 16th St, Greensboro, NC 27405 336-808-7296 Biren.Patel@averyden 8/12/2014 Page 8111/2014 catiAaate of cawa0 e STATE OF NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES DIVISION OF ENERGY, MINERAL AND LAND RESOURCES GENERAL PERMIT NO. NCG170000 CERTIFICATE OF COVERAGE; No. NCG170420 STORMWATER DISCHARGES NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM In compliance with the provision of North Carolina General Statute 143-215.1, other lawful standards and regulations promulgated and adopted by the North Carolina Fnvirontrtentnl Management Conmilssion, and the Federal Water Pollution Control Act, as amended, Avery Dennison is hereby authorized to discharge stormwater from a facility located at Avery Dennison 950 German St Lenoir Caldwell County to receiving waters designated as Spainhour Creek, class C water(s) in the Catawba River Basin(s) in accordance with the stormwater pollution management requirements, monitoring and reporting requirements, and other conditions set forth in Parts I, II, III and 1V of General Permit No. NCG170OW as attached. This certificate of coverage shall become effective August 1, 2014. This Certificate of Coverage shall retrain effective for the duration of the General Permit. Signed this day August 1, 2014. for Tracy E. Davis, P.E., CPM Director, Division of Energy, Mineral and Land Resources By the Authority of the Environmental Management.Comrnission 111 Georgoulias, Bethany From: Todd Horton <todd.horton@averydennison.com> Sent: Friday, August 15, 2014 4:41 PM To: Georgoulias, Bethany Cc: Biren Patel Subject: COC Attachments: SWPPP COC 2014.pdf Bethany, Here is the copy of the COC that I printed on 8/11/2014 for confirmation. Also, I mailed the original copies of the NPDES Permit Owner Affiliation Designation Form and the NPDES Contact Su unary. Thanks. Todd Horton EHS Specialist Avery Dennison - RBIS 950 German Street Lenoir, NC 28645 . . Office : 828-758-3450 Cell: 828-358-6538 Fax : 828-759-1913 The information transmitted is intended only for the person or entity to which it is addressed and may contain confidential and/or privileged material. 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