NCS000328_Owner Affiliation Change and Signature Authority Desig_20211214

Georgoulias, Bethany
From:
Sent:
Georgoulias, Bethany
Tuesday, December 14, 2021 10:11 AM
To: [e-mail]
Cc: 'Bill Ford'; 'Richard Petrovich'; 'Connor Burke'; Young, Brianna A; Carson, Brittany
Subject: RE: NCS000328 Owner Affiliation Change and Delegation of Signature Authority
Good morning,
Thank you for alerting us to the updates. We have updated the contact information for this permit:
Permit: NCS000328 Version: 3.0 Status: dive
Entity
*.Afri I i ati o n Type
Name
Title
Phone Number
Facility
Contact Person
Ford, Bill
General Man...
[phone]
Dwner
Contact Person
Ochs, Karl
[phone]
Dwner
Owner
Ford, Bill
General Man...
[phone]
Permit
Billing
South, Bestway
Permit
Contact Person
Ford, Bill
General Man...
[phone]
Permit
Has Permit Signature Authority
Burke, Connor
[phone]
Permit
Has Permit Signature Authority
Petrovich, Rick
[phone]
Tomorrow morning you can run a Permit Contact Summary Report and confirm all information is correct. The
information for the report will update overnight.
Best regards,
Bethany Georgoulias (she/her)
Environmental Engineer
Stormwater Program, Division of Energy, Mineral, and Land Resources
N.C. Department of Environmental Quality
919 707 3641 office
[e-mail]
512 N. Salisbury Street, Raleigh, NC 27604 (location)
1612 Mail Service Center, Raleigh, NC 27699-1612 (mailing)
Website: http://deq.nc.gov/about/divisions/energy-mineral-land-resources/stormwater
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties
Based on the current guidance to minimize the spread of COVID-19, the Department of Environmental Quality has
adjusted operations to protect the health and safety of the staff and public. Many employees are working remotely or
are on staggered shifts. To accommodate these staffing changes, all DEQ office locations are limiting public access to

appointments only. Please check with the appropriate staff before visiting our offices, as we may be able to handle your
requests by phone or email. We appreciate your patience as we continue to serve the public during this challenging
time.
From: [e-mail] [mailto:[e-mail]]
Sent: Friday, December 3, 2021 11:05 AM
To: Georgoulias, Bethany<[e-mail]>; Carson, Brittany <[e-mail]>; SW-
eDMR <[e-mail]>
Cc: 'Bill Ford' <[e-mail]>;'Richard Petrovich' <[e-mail]>;'Connor Burke'
<[e-mail]>
Subject: [External] NCS000328_NPDES SW Permit Owner Affiliation Change and Stormwater Permit Delegation of
Signature Authority Forms and Contact Changes for Bestway South, Inc.
Importance: High
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Report Spam.
Bethany, Brittany, and eDMR SW Administrator,
Please find attached copies of the NPDES SW Permit Owner Affiliation Change Request form as well as the
Stormwater Permit Delegation of Signature Authority Form on behalf of our client, Bestway South, Inc.
Original signed copies of both forms have been mailed to the appropriate NCDEQ-DEMLR address in Raleigh
and the Owner affiliation form was uploaded online.
The following contact information and changes for Bestway South, Inc., NPDES SW Permit NCS000328 are
being requested.
New Permit Owner Affiliation, Facility, and Permit Contact for NCS000328, Bestway South, Inc.
Bill Ford, General Manager
[e-mail]
704-585-6373
Bestway South, Inc.
165 Halyburton Rd
Stony Point, NC 28678
Please also note that prior to the Management Change at the facility that occurred this week, we had
previously submitted the eDMR Registration Form designating Mr. Rick Petrovich, General Manager as the
Facility Administrator for eDMR reporting. If this can be changed to Mr. Bill Ford, General Manager, we would
greatly appreciate it. If we need to submit a new Stormwater eReporting Registration Form designating Mr.
Ford as the Facility administrator, please let us know. Otherwise please update your records in the eDMR
system with Bill Ford's information. Thank you.
Please update your records for this permittee NCS000328 as requested above. Thank you.
On behalf of:
Bill Ford, General Manager

[e-mail]
704-585-6373
Bestway South, Inc.
165 Halyburton Rd
Stony Point, NC 28678
SW Permit: NCS000328
If you have any questions, concerns, or require additional information for the above requests, please let us
know. You may contact either Mr. Willard of INENCO, INC. or Mr. Bill Ford, General Manager of Bestway
South, Inc.
Thank you for your time and assistance in this matter. Have a blessed day and Holiday Season.
James
James W. Willard II, CSP, CHMM, MESH
Vice President / Senior Consulting Project Manager
4i��
INENCO, Inc.
132 W. Statesville Ave.
Mooresville, NC 28115
Phone: [phone]
Fax: [phone]
Mobile: [phone]
Email: [e-mail]
Notice: The information contained in this communication is confidential and may be legally privileged. It is intended solely for the use of the individual or entity to
whom it is addressed and others authorized to receive it. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or
taking any action in reliance of the contents of this information is strictly prohibited and maybe unlawful. INENCO, Inc. is liable for neither the proper and complete
transmission of the information contained in this communication nor for any delay in its receipt. If you have received this message in error, please notify us
immediately by replying to the message and deleting it from your computer. Thank You.

Division of Energy, Mineral, and Land Resources
Land Quality Section 1 Stormwater Program
National Pollutant Discharge Elimination System. (NPDES)
PERMIT OWNER AFFILIATION DESIGNATION FORM
twrd l�esourrces
v,+neowoauouurrn (Individual Legally Responsible for Permit)
Use this form if there has been:
FOR AGENCY USE ONLY
Date Received
Year
Manth
Day
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
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 Af%liation")
applies:
Individual Permit
N I C I 5 10 0 10 13 12 18
2) Facility Information:
Facility name-
Company/Owner Organization:
Facility address:
(or) Certificate of Coverage or No Exposure
N C G
Bestway South, Inc.
Bestway South, Inc.
165 Halyburton Rd
Address
Stony Point NC 28678
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
http s: //deg , nc. goy/about/division slene gy-mineral-1 and-resources/energy-m iner_al -land-permits/npdes-industri al-
ropgrram and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Rick
Petrovich
First MI bast
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: Bill Ford
First M1 Last
Page 1 of 2
5 wU-0"E RAF F1L4Nov2Q l9

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
General Manager
Title
165 Halyburton Rd
Mailing Address
Stony Point NC 28678
City State Zip
( 704 ) 585-6373 [e-mail]
Telephone E-mail Address
(704 ) 585-6287
Fax Number
5) Reason for this change:
A result of:
0 Employee or management change
❑ Inappropriate or incorrect designation before
❑ Other
If other please explain:
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
I, Rick Petrovich , 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.
11 /30/2021
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: h :llde .ne. ov/about/divisions/ener -mineral-land-resources/stormwater
Page 2 of 2
SVVU-0WNERAFFIL-4Nov2019

NC Department of Environmental Qualify
Division of Energy, Mineral and Land Resources
N0117H CAROLINA
EffemwrQuWrry
Stormwater Permit Delegation of Signature Authority Form
❑irections are in red.
=> This form shall be used to delegate signature authority from the permit Owner (Permittee) to
another party. Only the Responsible Official defined below may submit permit applications and
reports required by the permit (such as Data Monitoring Reports and Annual Reports) until this
form is completed and submitted to the DEMLR Stormwater Program. Please note that delegating
signature authority does not relieve the Permit Owner from the responsibility for permit
compliance.
The permit Owner is the legal entity to which/whom a permit has been issued, and may be an individual
or an organization such as a company or government agency. Every Owner is required to have a
Responsible Official who meets the legal signature authority requirements in 40 CFP._ 122.22, summarized
below.
■ For a corporation, the Responsible Official shall be a president, secretary treasurer, or vice-
president in charge of a principal business function, or another individual who performs similar
functions for the corporation, or the manager of one or more manufacturing, production, or operating
facilities who is authorized to make management decisions about the facility operation.
• For a partnership or sole proprietorship, the Responsible Official shall be a general partner or the
proprietor, respectively; or
• For a municipality, State, Federal, or other public agency, the Responsible Official shall be either a
principal executive officer [CitylCounty Manager] or ranking elected official [Mayor].
=> Even if delegated signatory authority has been delegated to another individual, the Responsible Official
retains responsibility for compliance with permit conditions.
Permittee.
Permit Number:
Responsible Official Title:
Email Address: —
Mailing Address:
City;
Bill Ford
NCS000328
General Manager
[e-mail] Phone: [phone]
165 Halvburton Rd
Stony Point
State: INC I ZiP: 128678
Stormwater Delegation of Signature Authority Form
Page 1

A. Persons to Receive Signatory Authority
=> The signatures of the persons listed below indicates their acceptance of signatory authority.
Delegated Party Name:
Connor Burke
Delegated Party Title:
Operations Manager
Delegated Party Organization:
Bestway Enterprises, Inc.
Email Address:
[e-mail]
I Phone:
6o7-345-8944
Mailing Address:
3877 Luker Road
City:
Cortland
I State:
NY Zlp:
M45
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
11/30/2021
Delegated Party Name:
Rick Petrovich
Delegated Party Title:
Shop Manager
Delegated Party Organization:
Bestway South, Inc.
Email Address:
[e-mail]
I Phone:
704-585-6373
Mailing Address:
165 Halyburton Rd
City:
Stony Point
State:
NC
Zip:
28678
Signature of Delegated Party indicating
acceptance of Signatory Authority:
,
Date:
11/30/2021
Delegated Party Name:
Delegated Party Title:
Delegated Party Organization:
Email Address:
Phone:
Mailing Address:
City:
State:
Zip:
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
Delegated Party Name:
Delegated Party Title:
Delegated Party Organization:
Email Address:
Phone:
Mailing Address:
City:
state:
Zip:
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
Stormwater Permit Delegation of Signatory Authority Form
Page 2

B. Responsible Official Signature
The Responsible Official, as identified in accordance with 40 CFR 122.22, is the appropriate
individual with the authority to sign and submit reports for the organization.
As the Responsible Official, i, Bill Ford
have the authority to enter into this Agreement for
Bestwav South. Inc.
(Owner/Organization Name).
(printed name),
I request that the DEMLR Stormwater Program include the persons listed in Part A of this form
signatory authority for the above -named permit.
I acknowledge that I, and the persons listed in Part A of this form work at/for my organization
and have authority to act as a signatory for purposes of the NCDEQ's electronic document
systems.
By submitting this application, I, gill Ford (printed name),
have read, understand, and accept the terms and conditions of the stormwater permits) for
which I am the Responsible Official.
Responsible Official Signature
General Manager
Title
11 /30/2021
Date
Stormwater Permit Delegation of Signatory Authority Form
Page 3