NCG030503_Owner Affiliation Change_20201112

Energy. Mineral u
Land Resources
FNVIPONMENTAL QUALMY
Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater 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 AGE\CY USE ONLY
Date Received
Year
I Month
Day
NO CHANGE in facility ownership or facility dame, 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 aName-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);
A 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
C_1_s. 0 3 0 5 0 3 [.N._.IC I_._.G0 3 0 0 0 0
2) Facility Information:
Facility naive: Engineered Sintered Components
Company/Owner Organization: Sumitomo Electric Industries
Facility address: 250 Old Murdock Rd
Address
Troutman NC 28166
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
https://deg.ne. gov/about/divisions/energy-mineral-land-resources/en.el-gy-miiieral.-land-permits/npdes-industrial-
program and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Ryuehiro Goto
First M1 Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: Marty Todd
First MI Last
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Sit U-ONVNERAFFIL4Nov2019

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
Engineered Sintered Components
Title
250 Old Murdock Rd.
Mailing Address
Troutman NC 28166
City State Zip
(704 ) 528-7500 North Carolina 28166
Telephone E-mail Address
Fax Number
5) Reason for this change:
0 Employee or management change
A result of: [3 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, Marty Todd , 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.
l / 117 "o.2 C)
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
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