NCS000251_Owner Affiliation Change_20221130

DE Q Division of Energy, Mineral, and Laud Resources
rMNI.1 Y ia! �i1116.VNnfl�emV- Land Quality Section / Stormiyater Program
National Pollutant Discharge Elimination System (NPDES)
PERMIT OWNER AFFILIATION DESIGNATION FORM
(Individual Legally Responsible for Permit)
Use this form if there has been:
I'OR AGENCY USE ONLY
Date Rcceive
Year
Months
I 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 ranlcing elected official (for a municipality, state, federal or other public
agency);
• the general partner or proprietor (for a partnersliip 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
S.:O 0 10 12 15 11
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
(00 Certificate of Coverage or No Exposure
Conway Resin Plant
Bakelite Chemicals LLC
200 Ampac Road
Address
Conway NC 27820
city state . Zip
To find the current legally responsible person associated with your permit, go to this websitc:
littps://deg,iic.gov/sw/ Navigate to the "NPDES Industrial Program" section and run the Storiltrvater Permit
Contact Summary Report for your permit number,
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Robert E Dalton
MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit; Donald Bazinet
First MI
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Lasl revised 20 Fcb 2022

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
Director, Manufacturing
Title
P.O. Box 368
Mailing Address
Conway NC 27820
City State Zip
910 212-0669 [e-mail]
Telephone E-mail Address
(252 ) 586-1754
Fax Number
5) Reason for this change:
A result of: Q 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.
Note: 40 CFR 122.22(c) requires an original signature (not digital)
PEIRMITTEE CERTIFICATION;
1, Ronald Bazinet , attest that this application for this change in Owner Affiliation
(person lcgallyresponsibfofor 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.
S gtxatme Date
PLEASE SEND THE ORIGINAL SIGNED COPS' OF THE COMPLETED
OWNER AFFILIATION CHANGE FORM TO:
DEML,R - Stortxrwater Program
Dept. of Environunental 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.iic. ov/sw
Per NC General Statute 143-215.6B (i), any person who knowingly makes any false statement, representation, or
certification in any application, record, report, plan, or other document filed or required to be maintained under this
Article or a rule implementing this Article .. , shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars ($10,000).
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Dist revised 20 CcEr 2022