NCS000107_Owner Affiliation Change_20201109

Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
National Pollutant Discharge EIimination System (NPDES)
Energy. Mineral & 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
Dale Received
Year
WWI
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 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
INICIS1
2) Facility Information:
Facility name:
Company/Owner Organization
Facility address:
(or) Certificate of Coverage or No Exposure
N I C I C 10 10 10 10 7
Lanxess Corporation
Lanxess Corporation
520 Broome Rd
Address
Greensboro NC 27406
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
https://deg.nc.gov/about/divisions/energy-mineral-land-resources/enert,—v-tmineaa]-1and-I)ermits/nudes-industrial-
program and run the Permit Contact Summary Report
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual:
Michael
First
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
Vancil
M 1 Last
LaBarron O McMillian520
First MI Last
S WU-0WNERAFF1L4Nov2019
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NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
Plant Manager
Title
520 Broome Rd
Mailing Address
Greensboro NC 27406
city state zip
( 336 ) 378-0965 [e-mail]
Telephone E-mail Address
(336 ) 272-4312
Fax Number
5) Reason for this change:
El Employee or management change
A result of 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, LaBarron 0. McMillian , 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
proces
Za 2D
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: littp:lldeg.nc.(rov/about/divisions/energy-m ineraI-land-resourees/storm« ater
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5 WU-0WNERAFF1L4Nov20t9