NCG030212_Owner Affiliation Change_20220210

Prysmian
Group
January 25, 2022
Zahid Khan, Regional Engineer
NC Department of Environmental Quality
Division of Water Quality
Mooresville Regional Office
610 East Center Avenue
Mooresville, NC 28115
CERTIFIED MAIL
RETURN RECEIPT REQUESTED
7019 1640 0002 2899 0530
�PPRYSMIAN
- Draka
Subject: Responsible Official and HSE Manager Change
(General Stormwater Permit #NCG030212)
Prysmian Cables and Systems USA, LLC. (formerly Draka Communications Americas, Inc.)
Claremont, North Carolina
IT-PrHM , oTMo
Responsible Official for Prysmian Cables and Systems USA, LLC Steve Linden, Site Director ,is being changed
to Glenn Peterson, Fiber Plant Director ( lg enn.petersonAprysmiangroup.com, phone # [phone]).
Contact Point Rick Miller, HSE Manager, is being changed to Jeff Roseberry, HSE Manager
(jef£roseberry( ,prysmiangroup.com, (Phone # [phone]). These changes are effective immediately.
If you have any question, please contact Jeff Roseberry at 704-437-4587.
Best Regards
Rick Miller
HSE Manager
Prysmian Cables and Systems USA, LLC
PO Box 39, 2512 Penny Road, Claremont, NC 28610
Tel: [phone] Fax [phone]

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 (Individual Legally Responsible for Permit)
ENVInd Reso Tres
Use this form if there has been:
FOR AGENCY USE ONLY
Date Received
Year
Momh
Day
RECEIVE®
NO CHANGE in facility ownership or facility name, but the indiATER
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 (or) Certificate of Coverage or No Exposure
N I C I S I I IN I C I G 101310 9-
2) Facility Information:
Facility name: C„ b6 qK( SySfe..S, LiSA aC
Company/Owner Organization:
Facility address: P�_Any IQc(
' Address
�.{af GnotY� �) G
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
https://deg.nc. go v/about/divisions/energy-mineral-I and-resources/energy-mineral-land-permits/npdes-industrial-
rp ogram and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
1
Previous legally responsible individual: fite. K e,
First MI last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
l7�nn I'��SOr
First MI Last
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S WU-O WNERAFFIIANov2019

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
F. 0tlrejrv—
//�� Title
2512 1'Gnn�. Q`i
Mailing Address
City State Zip
`F59-45--7 olur.pefei ,a
E-maSaSo.�wv�,cc.*
Telephone il Address
Fax Number
5) Reason for this change:
Employee or management change
A result of: ❑ Inappropriate or incorrect designation before
❑ Other
If other please explain:
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
1, �q l 2VkVl Nc'l2,`50 r 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.
4� \ � zfo / -2- -z-
Signature Date
PLEASE SEND THE COMPLETED FORM TO:
DEMLR - Stonnwater 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
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S WU-O WNERAFFIL-4Nov2019