NCG180112_Owner Affiliation and Other Contact Updates_20220106

Georgoulias, Bethany
From: Holland, James (HBF) <[e-mail]>
Sent: Thursday, January 6, 2022 2:46 PM
To: Georgoulias, Bethany
Subject: [External] RE: NPDES Stormwater Database Changes
Attachments: 2022 01-05 Signed - NPDES-Owner-Affiliation-Change.pdf, 2022 01-05 Signed - SW-
DOSA-Form.pdf
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Report Spam.
Hi Bethany,
I appreciate the help, and I have attached the completed forms you sent. I have also reviewed the Permit Summary
Report and found only one permit listed as noted on the attached documents.
The Owner Contact Person(s)
Justin A. Storer Director/General Manager
0492 [e-mail]
The following will all be the same:
Facility Contact Person(s)
Permit Contact Person(s)
Permit Billing Contact(s)
James T. Holland II EHSS
7530 holland*@hbf.com
The following will all be the same:
Person(s) with Delegated Signatory Authority
Person(s) with Electronic Signature Authority
James T. Holland II EHSS
7530 [e-mail]
Joe D. Craig Facilities
4169 [e-mail]
Luke D. Barger Plant Manager
6969 [e-mail]
PO Box 8, Hickory, NC 28603 (563) 506-
PO Box 8, Hickory, NC 28603 (828) 302-
PO Box 8, Hickory, NC 28603 (828) 302-
PO Box 8, Hickory, NC 28603 (828) 312-
PO Box 8, Hickory, NC 28603 (828) 234-
Please let me know what the next steps are to completing the information update.
Thank you again.
Regards,
James
From: Georgoulias, Bethany <[e-mail]>
Sent: Tuesday, January 4, 2022 5:30 PM
1

To: Holland, James (HBF) <[e-mail]>
Subject: Re: NPDES Stormwater Database Changes
James,
I'll be away most of the morning on Wednesday and will not be available by phone. I will try to send some information
to help in the meantime.
I cannot help much with eDMR, and our administrative position doing that is vacant right now. But we can try to get the
permit information straightened out.
If there has been a change in Legally Responsible Person (Owner Affiliation), the new person needs to sign the attached
form and return it to us. I can make the change in our database if I get a scanned copy by email. Then that person can
fill out the DOSA form to delegate signature authority the appropriate person if that has not been done already. We can
record that in our database if provided.
As far as other contacts, please review the Permit Summary Report [reports.ncdenr.orgl for your permit and provide us
with updates. We will do our best to make those soon, but we are lagging behind without administrative assistance at
the moment.
The important part will be checking to see if the Owner is attached to multiple permits. We will check that when we go
to revise the legally responsible person. It's important because a change to it will affect all the permits that owner is
attached to.
Thanks,
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 [deq.nc.govl
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties
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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: Holland, James (HBF) [mailto:[e-mail]]
Sent: Tuesday, January 4, 2022 4:14 PM
To: Georgoulias, Bethany<[e-mail]>
Subject: [External] NPDES Stormwater Database Changes
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
Good Afternoon Ms. Georgoulias,
I seem to have run into some issues with updating the information on our permit. I was attempting to file an eDMR and
realized my mistake while walking through the verification process. I am not required to do analytical analysis and see
no reason I will in the future, but wanted to utilize the system.
Although, I do not need to make any change to Name/Ownership or address, I do need to change most everything
else. I had verbally changed this information in the past (2018) via the phone and with the NCDEQ Inspector we had on -
site in 2021. Unfortunately, when I pulled the required reports, I found that the information was not only pre-2018, but
had not been correct even then.
I could use assistance on getting the contacts and signatory updated appropriately. From the looks of it, I would need
the signature of the "Legally Responsible Person", who is no longer available. Also, I am concerned if my local Signatory
Authority could also be listed as the Owner Affiliation instead of needing to utilize our corporate director, located in
Iowa? In the past, a signatory authority could be placed as Owner Affiliation, but wanted to be sure.
Please contact me at my email/phone number, at your earliest convenience via email or between 7 AM and 4 PM via
phone.
Thank you,
James
James T. Holland II
EHSS Manager
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4

Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
Energy, Mineral & PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resources
ENVIRONMENTAL QUALITY (Individual Legally Responsible for Permit)
Use this form if there has been:
FOR AGENCY USE ONLY
Date Received
Year
Month
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 Affiliation")
applies:
Individual Permit 01) Certificate of Coverage or No Exposure
N I C I S N I C I G 11 18 10 11 11 12
2) Facility Information:
Facility name: Hickory Business Furniture
Company/Owner Organization: HNI Corporation
Facility address: 900 1 2ti, St. Dr. NW
Address
Hickory NC 28601
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
https:Hdeg nc gov/about/divisions/energy-mineral-land-resources/energy-mineral-land-permits/npdes-industrial-
ro ram and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Paul Owens
First MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: Justin A Storer
First Last
Pagel of 2
S WU-0WNERAFFIL4Nov2019

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
Director / General Manager
Title
PO Box 8
Mailing Address
Hickory NC 28603
City State Zip
( 563 ) 506-0492 [e-mail]
Telephone E-mail Address
(828 ) 415-7060
Fax Number
5) Reason for this change:
A result of: 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, Justin A. Storer , 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
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.nc.gov/about/divisions/energy-mineral-land-resources/stormwater
Page 2 of 2
S WU-0WNERAFFIL-4Nov2019

NC Department of Environmental Quality
Division of Energy, Mineral and Land Resources
NORTH CAROLINA
Environmental Quality
Stormwater Permit Delegation of Signature Authority Form
Directions 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 whichAvhom 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 CFR 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 [City/County 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:
Justin A. Storer
Permit Number:
NCG180112
Director / General Manager
Responsible Official Title:
Email Address:
[e-mail]
Phone:
[phone]
Mailing Address:
PO Box 8
City:
Hickory
I State:
NC
Zip:
�28603
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:
James T. Holland II
Delegated Party Title:
Environmental, Health, Safety, and Sustainability Coordinator
Delegated Party Organization:
Hickory Business Furniture
[e-mail] Phone: [phone]
Email Address:
Mailing Address:
PO Box 8
City:
Hickory F CTS,
ate:
NC
Zip:
28603
Signature of Delegated Party indicating
acceptance of Signatory Authority:
Date:
01/05/2022
Delegated Party Name:
Joe D. Craig
Delegated Party Title:
Facilities Manager
Delegated Party Organization:
Hickory Business Furniture
Email Address:
[e-mail]
I Phone:
[phone]
Mailing Address:
PO Box 8
City:
Hickory
I State
NC
Zlp:
28603
Signature of Delegated Party indicating
acceptance of Signatory Authority:
L�
Date:
OP6512022
Delegated Party Name:
Luke D. Barger
Delegated Party Title:
Plant Manager
Delegated Party Organization:
Hickory Business Furniture
Email Address:
[e-mail]
Phone:
[phone]
Mailing Address:
PO Box 8
City:
Hickory
I State
NC
I Zip:
28603
Signature of Delegated Party indicating
acceptance of Signatory Authority:
_,Q
J(j
Date:
01 /05/2022
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, Justin A. Storer
have the authority to enter into this Agreement for
HNI Corporation
(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, Justin A. Storer (printed name),
have read, understand, and accept the terms and conditions of the stormwater permit(s) for
which I am the Responsible Official.
Respofisible Official Simature
Director / General Manager
Title
01 /05/2022
Date
Stormwater Permit Delegation of Signatory Authority Form
Page 3