NCG030429_Owner Affiliation Change_20210310

DiViSion-of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
FOR AGENCY USE ONLY
Date Received
Year -
Mouth
Day ---
-_ -National Pollutant Dischai e Elimination S stern DES =
w g Y (NP. )
Energy, Mill erat & PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resources
ENVIRONMEN7 AL QUALITY (Individual Legally Responsible for Permit)
------ _ _._ _.. --------------
Use this -form if there .has been-:.......
who is legally responsible for the permit has changed
- -
--:If-the name-ofthe-facilityhas changed, nor ifthe ownership-ofthe-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.
I) Enter the permit number for which this change in Legally Responsible Individual ("Owner Affiliation")
applies:
Individual Permit (01) Certificate of Coverage or No Exposure
N, C S N C' G` 0 3 0 4 2 9
2) Facility Information:
Facility name: GKN Driveline Roxboro
Company/Owner Organization: GKN
Facility address: 6400 Durham Road
Address
Timberlake NC 27583
City state zip
To find the current legally responsible person associated with your permit, go to this website:
littps://deq.nc.gov/about/divisions_/energy-mineral-land-resources/eaiergy-mineral-land-permits/npdes-industrial-
ro ram and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Charles Hopkins
First M1 Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: Lacy Harris
- - -
....Firs}.. .. MI _ Last...
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S WU-O WNERAFFIL4Nov2o 19

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
. . Title
Mailing Address
��,, 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, Lacy Harris , 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.
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: litt tilde .iie.7lov/abOut/divisions/ever-i-nineral-laiid-resoLirces/stormwater
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