NCG170234_Owner Affiliation Change_20210331

Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
K--r,o National Pollutant Discharge Elimination System (NPDES)
frierLando, Lone Mineral a PERMIT OWNER AFFILIATION DESIGNATION FORM
�aR(t lipSOUI'CFS
�,0„ (Individual Legally Responsible for Permit)
Use this form if there has been:
FOR AGENCY USE ONLY
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NO CHANGE in facility ownership or facility name, but the individual
who is legally responsible for the permit has changed.
N 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 (or) Certificate of Coverage or No Exposure
N IC IS I I I I I I I N I C I G 1 17 0 12 13 14
2) Facility Information:
Facility name: Kayser -Roth Corp - Asheboro Plant
Company/Owner Organization: Kayser -Roth Corporation__
Facility address: 515 West Balfour Ave
Address
Asheboro NC 27203
oily 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-resourcesle nerdy-mineral-land-permits/nudes-industrial-
roP gram and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Kevin Toomey
First MI last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
Nicola Gallotti
First MI Lit
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NPDES Stormweter Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
President and CEO
Title
102 Corporate Center Blvd
Mailing Address
Greensboro NC 27408
City State Zip
_(336 ) 547-46o5 nicolagallotti0kayser-roth.c
Telephone E-mail Address
Fax Number
5) Reason for this change:
A result of
[l Employee or management change
❑ 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. I nitderstand that if all required parts of this form are not completed, this change may not be
p ,
411121
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-resourcesistormwater
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