NCG170228_Owner Affiliation Change_20210331

Division of Energy, Mineral, and Land Resources FUR AGEN YUSE ONLY
Land Quality Section / Stormwater Program y-
Kra National Pollutant Discharge Elimination System (NPDES)
Eifel Vy. Millerul is PERMIT OWNER AFFILIATION DESIGNATION FORM
t. and Rewurcrs
a *C.00.1.t Qu.t'". (Individual Legally Responsible for Permit)
Use this Form if there has been:
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 ownersh/v 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 (or) Certificate of Coverage or No Exposure
N G S II I I IN I C I G 11 17 10 12 12 16
2) Facility Information:
Facility name: Kayser -Roth Corp - Burlington Plant
Company/Owner Organization: Kayser -Roth Corporation _
Facility address: 714 Interstate Service Rd
Address
Graham NC 27253
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
h_tlps: //deg.nc.gov/abouUdi vision5'energy-m i nera 1-I and-resources/energy-m i neraI-land-permits/npdes-industrial-
program and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Kevin Toomey
First N41 Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
Nicola Gallotti
First MI Last
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S WU-0WNERAFFEL4Nov2019

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
President and CEO
Tide
102 Corporate Center Blvd
Mailing Address
Greensboro NC 27408
City Slae zip
ass 547-46os nicola allotti@ka ser-roth.c
Telephone E-mail Address
Fax Number
5) Reason For this change:
[l 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, Laval Choiniere , 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. �understand that if all required parts of this form are not completed, this change may not be
processed.
4/1 /21
Signature Date
PLEASE SEND THE COMPLETED FORM TO.
DEMLR - Stormwater Program
Dept. of Environmental Quality
16I2 Mail Service Center
Raleigh, North Carolina 27699-1612
For more information or staff contacts, please call [phone] or visit the website
at: h ://de .nc. ov/about/divisions/ener -mineral-land-resources/stormwater
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S WU-O WNEFAFHL-0Nov20l9