NCG060264_Owner Affiliation Change_20211101

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Energy. Mineral &
Land Resources
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Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
FOR AGENCY USE ONLY
De[e Received
Year
I Month
I Day
National Pollutant Discharge Elimination System (NPDES) N C Department of
Environmental Quality
PERMIT OWNER AFFILIATION DESIGNATION FORM Received
(Individual Legally Responsible for Permit) NOV 0 1 2021
Use this form if there has been: Winston-Salem
Re pqa O ice
NO CHANGE in facility ownership or facility name, but the in lvl u I
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.
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
N I C I S I I I N I C I G 10 160 2 6 4
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
Procter & Gamble Manufacturing Co - Swing Road
The Proctor & Gamble Manufacturing Company
100 South Swing Road
Address
Greensboro NC 27409
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
hitps: //deg. nc. gov/about/divisions/energy-mi nera l -I and-resources/energy-m i nera I -I and-permits/npdes-i ndListria I-
rp ogram and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Ron Matuslak
First MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
Elke Feierabend
First MI Last
Page 1 of 2
S W U-O WNERAFFI1-4Nov2019

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:
Plant Manager
Title
100 South Swing Road
Mailing Address
Greensboro NC 27409
City State Zip
(336 ) 315-6755 [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 Elke Feierabend , 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.
0,& 27 26 2
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.ne.gov/about/divisions/energv-mineral-land-resources/stormwater
Page 2 of 2
S WtJ-O WNE RAM L-4Nov20l9

NCDEQ Division of Energy, Mineral and Land Resources
Stormwater Discharge Monitoring Report (DMR) Form for NCG060000
Food and Kindred
Click here for instructions
Complete, sign, scan and submit the OUR via the Stormwater NPDES Permit Data Monitoring Report (DMR) Upload form within
30 days of receiving sampling results. Mail the original, signed hard copy of the DMR to the appropriate DEMLR Regional Office.
Certificate of Coverage No. NCG06 0264
person Collecting Samples: N/A
Facility Name:Procter& Gamble Manufacturing Co -Swing Road
Laboratory Name: waypoint Analytical
Facility County: Guilford
Laboratory Cert. No.:402
Discharge during this period:
Yes
No (if no, skip to signature and date)
Has your facility implemented mandatory Tier response actions this sample period for any benchmark exceedances? Yes ❑ No
If so, which Tier (I, II, or III)?
A copy of this DMR has been uploaded electronically via https://edocs.deg.nc.gov/Forms/SW-DMR Yes No
Date Uploaded:
Analytical Monitoring Requirements for Outfalls with Industrial Activities— Benchmarks in (Red)
Parameter
Parameter
Outfall a001
Outfall
Outfall
Outfall
Outfall
Code
N/A
Receiving Stream Class
N/A
Date Sample Collected MM/DD/YYYY
46529
24-Hour Rainfall in inches
C0530
TSS in mg/L (100 or 50•)
pH in standard units (6.0-9.0 FW,
00400
6.8-8.5 SW)
00556
Oil & Grease in mg/L (30)
Fecal Coliform per 100 ml of
31616
freshwater (if required) (1000)
Enterococci per 100 ml of saltwater
61211
(if required) (500)
Chemical Oxygen Demand in mg/L
00340
(120)
Additional parameters for outfalls in drainage areas that use >55 gallons per month of new hydraulic oil on average
Estimated New Motor/Hydraulic Oil
NCOIL
Usage in gal/month
00552
Non -Polar Oil & Grease in mg/L (15)
• Outfalls to Outstanding Resource Waters (ORW), High Quality Waters (HQW), Trout Waters (Tr) and Primary Nursery Areas (PNA)
have a benchmark TSS limit of 50 mg/L. All other water classifications have a benchmark of 100 mg/L
FW (Freshwater) SW (saltwater)
Notes (optional):
"I certify by my signature below, under penalty of law, that this document and all attachments were prepared under my direction or supervision in
accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my
inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information
submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting
false information, including the possibility of fines and imprisonment for knowing violations."
2 o 2 /l
Signature of Permittee or Delegated Authorized Individual Date
[e-mail]
Email Address
336-315-6854
Phone Number