NCS000255_Owner Affiliation and Other Contact Changes_20230103

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 OUALITY (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 (or) Certificate of Coverage or No Exposure
N I C I S 10 0 0 12 1 N I C I G
2) Facility Information:
Facility name: Grede II, LLC
Company/Owner Organization: Grede II, LLC
Facility address: 530 East Main Street
Address
Biscoe NC 27209
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
littps:Hdeg.iic.gov/about/divisions/energy-mineral-land-resources/energy-mineral-land-permits/npdes-industrial-
rop gram and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Richard Morford
First Ml Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
Matt Mullins
First MI Last
S WU-OWNERAF FI[ANov2019
Page I of 2

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
5) Reason for this change:
A result of:
tf ether please explain:
Plant Manager
Title
530 East Main Street
Mailing Address
Biscoe NC 27209
City State Zip
910 ) 428-2111 [e-mail]
Telephone E-mail Address
( 910 ) 428-1295
Fax Number
✓l Employee or management change
Inappropriate or incorrect designation before
❑ Other
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
1, Matthew Mullins , 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.
12/21 /2022
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.ne.Gov/about/divisions/energy-mineral-land-resources/stormwater
Page 2 of 2
S WU-0WNERAFFIL-4Nov2019

Georgoulias, Bethany
From: Georgoulias, Bethany
Sent: Tuesday, January 3, 2023 4:41 PM
To: Ariel Dawson (WAI)
Cc: Jeffrey E. Willoughby (WAI); Mark Ferrell (WAI); Tyler Carrico (WAI); Emory Willoughby
(WAI); Young, Brianna A
Subject: RE: [External] Grede II LLC (NCS000255) Stormwater eDMR Registration Steps 1-2
Attachments: SW-DOSA-Form-2022051 1 -DEMLR-SW.pdf
Ariel,
I have made the updates to Owner Affiliation as well as to the facility and permit contact details. Please run a permit
contact summary report in the morning to verify that everything is correct.
The original signed copies of the Owner Affiliation form and the eDMR registration form need to be mailed in to our
office. There may also be a Delegation of Signature Authority (DOSA) form required for eDMR if it hasn't been
completed already. Please see attached if you need that. Contact Brianna Young with any questions about the eDMR
registration.
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/stormwatgr
cc. ��� DE
NORTH CAROLINA p
Department of Environmental Duality
Email correspondence to and from this address is subject to the North
Carolina Public Records Law and may be disclosed to third parties.
From: Ariel Dawson (WAI) <[e-mail]>
Sent: Wednesday, December 21, 2022 12:16 PM
To: [e-mail]
Cc: Jeffrey E. Willoughby (WAI) <[e-mail]>; Mark Ferrell (WAI) <[e-mail]>; Tyler
Carrico (WAI) <[e-mail]>; Emory Willoughby (WAI) <[e-mail]>; Georgoulias,
Bethany<[e-mail]>; Young, Brianna A <[e-mail]>; Selkane, Aziza

<[e-mail]>
Subject: [External] Grede II LLC (NCS000255) Stormwater eDMR Registration Steps 1-2
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
Suzanne —
Good afternoon. I hope you are doing well.
Attached "eDMR Owner Verification Report" requires update per the following:
1. Responsible Official: Matt Mullins
2. Resp. Official Title: Plant Manager
Attached "NPDES Stormwater Permit Summary' requires update per the following:
Legally Responsible for Permit-
1. Owner Affiliation: Matt Mullins (Note: Completed Permit Owner Affiliation Designation Form
attached.)
2. Title: Plant Manager
3. Email Address: [e-mail]
Facility Contact Person(s) & Permit Contact Person(s) —
1. Phone: [phone] Ext.3279
2. Email: [e-mail]
Finally, a completed Electronic Reporting Registration Form is attached. What will be the next step? Will we be
contacted with further instruction?
Call or email with any questions. Thank you!
Thank you,
Ariel
Ariel Dawson
Willoughby & Associates, Inc.
15421 Forest Road, Suite A
Forest VA 24551
Office: [phone]
Cell: [phone]