NCG030108_Owner Affiliation Change_20210729

Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
Energy, Afteral6 PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resources
EHIAONHEHIAL u ~ 11 (Individual Legally Responsible for Permit)
FOR AGENCY USE ONLY
Dale Rccelrcd
Year
Manlh
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 changed,
do NOT use this form. Instead, you must rill 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.
l) Enter the permit number for which this change in Legally Responsible Individual ("Owner Affiliation")
applies:
Individual Permit (01) Certificate of Coverage or No Exposure
N IC ISI I I I J= INICIG10 13 10 11 0$
2) Facility Information:
Facility name:
Company. -'Owner Organization:
Facility address:
Railroad Fricition Products Corporation
Railroad Friction Products Corporation
13601 Airport Road
Address
Maxton NC 28364
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
htt s:llde .nc. ov/about/divisions/ener -_mineral-land-resources/energy-mineral-land-pt!rmirs/nudes-industrial-
rp�ram and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Greg
First
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Thompson
Mt Last
Person legally responsible for this permit: Mall _ Jarusinski
First MI Last
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NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
5) Reason for this change:
A result of:
If other please explain:
VP and GM
Title
13601 Airport Road
Mailing Address
Maxton NC 28364
City State Zip
(910 ) 844-9712 [e-mail]
Telephone E-mail Address
9( 10 ) 844-8212
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,IT, 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.
tgnature
Data
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. decl_nc_tov abouUdivisions.'energy-mineral-Iand -resourceslstormwater
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