NCG170240_Owner Affiliation Change_20210331

Division of Energy, Mineral, and Land Resources
Land Quality Section f Stormwater Program
N, r-._ National Pollutant Discharge Elimination System (NPDES)
Energy, Minerui& PERMIT OWNER AFFILIATION DESIGNATION FORM
Cand Resources Individual L
=NVI�...L Q,..1,, ( Legally y Responsible for Permit)
Use this form if there has been:
FOR AGENCY USE ONLY
Dam RcccivW
Y.
Monh
1
NO CHANGE in facility ownership or facility name, but the individual
who is legally responsible for the permit has changed.
If the no of the facility has changed, or If the ownemi lv of the facility has changed,
do NOT use this form. Instead, you must flit 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 (ar) Certificate of Coverage or No Exposure
N C S N C G 1 7 0 2 14 Q
2) Facility Information:
Facility name: Kayser -Roth Corp - Lumberton Plant
Company/Owner Organization: Kayser -Roth Corporation
Facility address: 3707 West 51h St
Address
Lumberton NC 27358
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
https://dgg.nc. gov/about/divisions/energy-minera I-land-resources/energy-mineral-land-per-mits/npdes-industrial-
rp ogram 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 Last
Page 1 of 2
S Wtl-0WNERAFFQ; 4Nov2r119

NPOES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Cbange)
President and CEO
Title
102 Corporate Center Blvd
Mailing Address
Greensboro NC 27408
city slnie Zip
336 547-46o5 nicola allotti@ka ser-roth.c
Telephone E-mail Address
Fax Number
5) Reason for this change:
A result of: 0 Employee or management change
13 inappropriate or incorrect designation before
❑ Other
If other please explain:
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
I, 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 understand that if all required parts of this form are not completed, this change may not be
promised. -
4/1121
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, ov/about/divisions/energy-mineral-land-resources/stormwater
Page 2 of 2
s WU-0WNERAFFIL-4Nov2QI 9