NCG090021_Owner Affiliation_20210723

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Enet yMai orul &
Land Resources
ENVIRONMENTAL OVAL-7 V
Division of Energy, Mineral, and Land Resources
Land (duality Section 1 Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
PERMIT OWNER AFFILIATION DESIGNATION FORM
(individual Legally Responsible for Permit)
FOR AGENCY USE ONLY
DaIc kcc6n-d
Your
Month DRY
Use this farm 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 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 oIfiicial (ror a municipality, state, federal or othcr 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 (01I Certificate of Coverage or No Exposure
N I C I S I I I 1 1 1 N 1,9 1210 9 10 10 12 1
2) Facility Information:
Facility name: Akzo Nobel Coatings Incorporated
Company/Owner Organization: Akzo Nobel Coatings Inc
Facility address: 1431 Progress Avenue
Address
High Point NC 27261
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-rescurces/energy-mineral-land-perrnits!npdes-industrial-
rp ogram and run the Permit Contact Summary Report.
3) ❑LD OWNER AFFILIATION that should he rernoN ed:
Previous legally responsible individual: Janice
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
Mitchell
Milheim
Mt Last
Bruce
Nil l ❑cl
S VM-0 WNRR A F F11-4Nov201 H
Page 1 cal''

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Nasty/0anership Change)
5) Reason for this change:
A result of:
If other please explain:
Site Manager
Title
1431 Progress Avenue
Mailing Address
Hich Point NC 27261
City State Zip
(336 ) 259-0436 mitcheil.bruce@akzonobel,com
'telephone E-mail Address
Fax Number
❑r Employee or management change
® Inappropriate or incorrect designation before
❑ Other
Jhe certific ion below Lust be co pleted ani signed b he permit older.
PERMITTEE CERTIFICATION:
r Mitrhall Rnire e fle.. 161 lhis . _r.eel:.. s ehange .., n.. HO A rr,i...,,..,
tperson 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.
&-aj-L
Signature
C(,Izglzl
Date
PLEASE SEND THE COMPLETED FORM TO:
DEMLR - Ston-nwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
For more infnrtnation or staff contacts.. please call [phone] or visit the website
at: http://deg.nc.gov/about/divisions/energy-mineral-land-resources/storTnwater
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5 W!t-OWNS. RAFFM - Nor 2019