NCG030650_Owner Affiliation Designation_20210726

COMMSCOPE °
�ll-MP,l,- ���
6519 CommScope Road
Catawba, NC 28609
3642 US Hwy 70 East
July 21, 2021
James Moore
NCDEQ Mooresville Regional Office
Attn: DEMLR Stormwater Program
610 East Center Avenue, Suite 301
Mooresville, NC 28115
704-663-1699
Subject: CommScope, Inc.- Catawba Facility
Certificate of Coverage No. NCG030078
CommScope, Inc.- Claremont Facility
Certificate of Coverage No. NCG030650
Dear Mr. Moore:
Please find enclosed a Permit Owner Affiliation Designation Form to change the owner affiliation for
Permits #NCG030078 and #NCG030650 from Jeff Dixon to Terry Richardson. In addition, please find
attached the Stormwater eReporting Registration Form for both facilities.
Please feel free to contact me at 828-241-6037 with any questions.
Sincerely,
Laura R. Moody
Senior Environmental Engineer
Office phone: [phone]
Cell phone: [phone]
[e-mail].
Cc: James Moore, Mooresville Regional Office

FOR AGENCY USE ONLY
Date Received
Year
Month
Day
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 ownership of the facility has changetl;<<
do NOT use this form. Instead, you must fill out a Name -Ownership Change Form= ; ti
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
0 3 0 6 5 0
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
CommScope- Claremont
CommScope, Inc.
3642 US Hwy 70 East
Address
Claremont NC 28610
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
ht":Hdeg.ne. gov/about/divisions/energy-mineral-land-resources/energy-inineral-land-permits/npdes-industrial-
rp ogram and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Jeff
First
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
Terry
First
Page 1 of 2
Dixon
MI Last
Richardson
MI Last
S wU-O WNERAFF11ANov2019

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
5) Reason for this change:
A result of:
If Ptllerl"Ie'7Se
VP Operations, NAR
Title
6519 CommScope Road
Mailing Address
Catawba NC 28609
City State Zip
( 828 ) 241-6195 Terry. [e-mail]
Telephone E-mail Address
( )
Fax Number
❑✓ Employee or management change
® Inappropriate or incorrect designation before
❑ Other
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
I, Terry Richardson , 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.
r-
-7 ,
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://deq.ne.gov/about/divisions/energy-mineral-land-resources/stormivater
Page 2 of 2
S WU-O WNERAFFIL-4Nov2019