NCG180245_Owner Affiliation Form Signed_20211123

Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
FOR AGENCY USE ONLY
D"e Received
YM
Mouth
D
Energy, Mineral i PERMIT OWNER AFFILIATION DESIGNATION FORM RECEIVED
Land Resources (Individual Legally Responsible for Permit) ENVIRONMENTAL Reso rcesY
NOV
Use this form if there has been: DENR-LAND QUALM
NO CHANGE in facility ownership or facility name, but the inCjfW"TF_R PERM11TIP
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 I N I C I G 11 8 0 2 4 5
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
International Inc
218 Cline Park or
Address
Hildebran NC 28637
city State Zip
To find the current legally responsible person associated with your permit, go to this website:
https://deg.nc.gov/about/divisions/energy-mineral-land-resources/energy-mineral-land-perm its/npdes-i ndustrial-
rp ogram and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Jay Rubino
First MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
Kaitlyn Howells
First MI Last
Page 1 of 2
S WU•OWNERAFFaANav2019

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
Corporate Environmental Manager
Title
1235 Water Street
Mailing Address
East Greenville PA 18041
City State Zip
(610 ) 417-1063 [e-mail]
Telephone E-mail Address
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:
1, Kaitlyn Howells , 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.
�/7i W 6,f"0�
Signature
11/15/2021
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: htt ://de .nc. ov/about/divisions/ener -mineral-land-resources/stormwater
Page 2 of 2
S WU-OWNERAFFIL-4Nov2019

Tran, Kieu M
From: Kaitlyn Howells <[e-mail]>
Sent: Wednesday, March 16, 2022 8:38 AM
To: Tran, Kieu M
Subject: [External] RE: NCG18024S Owner Affiliation Change Form
Attachments: image001.emz; NCG18024S Owner Affiliation Change_.pdf-KH.pdf
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
Good morning Kieu,
Please see the signed form attached.
Thank you,
Kaitlyn
From: Tran, Kieu M <[e-mail]>
Sent: Monday, March 14, 2022 11:56 AM
To: Kaitlyn Howells <[e-mail]>
Subject: NCG180245 Owner Affiliation Change Form
CAUTION: This email originated from outside of the organization. Do not click links or open attachments unless you recognize the
sender and know the content is safe.
Good morning Kaitlyn,
I hope this email finds you well. While reviewing the Owner Affiliation Change form, I noticed that the form wasn't
signed. Can you please sign it and send it back via email?
Thank you,
Kieu Tran
Stormwater Program Administrative Assistant
Office: (919) 707- 3640
[e-mail]
North Carolina Department of Environmental Quality
Division of Energy, Mineral, and Land Resources Stormwater Program
512 N. Salisbury Street, Raleigh, NC 27604 (location)
1612 Mail Service Center, Raleigh, NC 27699-1612 (mailing)
Website: http:/Ideq..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