NCG030474_Owner Affiliation Change_20210803

Division of Energy, Mineral, and Land Resources
Land Quality Section 1 Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
=nerg 1,tii era/ & PERMIT OWNER AFFILIATION DESIGNATION FORM
Land eso,urces
:NVIRO NTA40UAUTY (Individual Legally Responsible for Permit)
FOR AGENCY USE ONLY
Date Received
Year
Month
Day
Use this form if there has been:
I' 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 official (for a municipality, state, federal or other public
I I agency);
oil 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 Pen -nit (or) Certificate of Coverage or No Exposure
N I C I S I I I I I I II G 10 13 10 14 17 14
2) Facility Information:
Facility name: LYNDON STEEL COMPANY, LLC
CornpanylOwner Organization: FABSOUTFI, LLC
'Facility address: 1947 UNION CROSS RD
Address
f. WINSTON SALEM NC 27107
City State Zip
III 11, '
To find the current legally responsible person associated with your permit, go to this website:
https://deg . ne.gov/about/divisions/energy-minera l-land-resources/energy-mineral-land-permits/npd es- industrial -
pro raan and run the Permit Contact Summary Report.
3) O U OWNER AFFILIATION that should be removed:
Previous legally responsible individual: CHRISTINE MACLAREN
First MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Penon legally responsible for this permit:
DANIEL J MAIDEN
First MI Last
Pagel of 2
SwU-OwNERAF F1L4Nov2014

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
is
EHS DIRECTOR
Title
1947 UNION CROSS RD
EIS
5) R ason for this change:
A result of:
If other please explain:
Mailing Address
WINSTON SALEM NC 27107
City State Zip
(336 ) 293-0316 [e-mail]
Telephone E-mail Address
f 336 1788-8835
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:
1, Daniel Maiden , attest that this application for this change in Owner Affiliation
(person legally responsible for the perinit) has been reviewed and is accurate and complete to the best of my
knowledge. I understand that if all required parts of this fonn are not completed, this change may not be
cssecl.
Signature
8/3/2021
PLEASE SEND THE COMPLETED FORM TO:
DEMLR - Storrawater Program
i' Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
Date
For more information or staff contacts, please call [phone] or visit the website
at: htt:llde .nc. ov/about/divisions/ener -mineral-land-resources/stonnwater
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