NCG070011_COMPLETE FILE - HISTORICAL_20180515

INRo
STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
IV C& b -1 bO j
DOC TYPE
HISTORICAL FILE
❑ MONITORING REPORTS
DOC DATE
❑ � lJ I p � 5 � �
YYYYMMDD

Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
a�*
National Pollutant Discharge Elimination System (NI'DES)
Energy, Minerul & PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resources
ENVORONN047AI QUA[)1V (Individual Legally Responsible for Permit)
Use this form if there has been:
FOR AGENCY USH ONLY
Date Reccircd
Year
%lomh Da
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 farm. Instead, you must fill out a N,3r�e f nle� shh -Change Form
and submit the completed form with all regtwre c meiAdtion.
What does "legally responsible individual" mean?
The person is either: CENTRAL RAL FILES
• the responsible corporate officer (for a corporation); 0WR SECTION
• 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
N I C I -S
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
(or) Certificate of Coverage
N I C I G 0 7 0 0 1 1
Lenox Corporation
1800 Dobbs Farm Rd.
Address
Kinston NC 28501
city state Zip
To find the current legally responsible person associated with your permit, go to this website:
lilt :llde .iic.,,ovlabout/(Iivisions/eiier<<v-mineral-land-resources/etier, mineral -land- ermits/storiliwater- ro4t:3rn
and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Paul
Leichtnam
First Mf Lust
4) NEW OWNER AFFILIATION (legally responsible for the permit):
� s eega�y't'�sponsible for this permit: Bob Lupica
MAY 10 2018 first Nit Last
DENR-LAND QUALITY Page 1 of 2
&'l X W►Nlff9RIPERNN4%W 17

NPDES Stormwater Permit OWNER AFFIL,ATION DESIGNATION Form
(if no Facility Name/Ownership Change)
5) Reason for this change:
A result Of. -
If other please explain:
VP of Manufacturing
"Title
1800 Dobbs Farm Rd.
Mailing Address
Kinston NC 28501
City r1 aa, state zip
(Zzm ) 559-t,5,6 uuu_luplud�wiertux.(;utn
Telephone
� E-mail Address
( zuz ) 6617 IXz
Fas Number
❑� Employee or management change
inappropriate or incorrect designation before
❑ Other
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
1, Bob Lupica , 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.
4/25/18
Sig tore 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: hit)://dec.nc.Iov/about/divisions/energv-mineral-land-resources/stormwater
RECEIVED
MAY 10 20U
swu-OWNFRAFr11 23Ma r2017
Page 2 of 2 DENR-LAND QUALITY
STORMWATER PERMITTING