NCG070049_Owner Affiliation Change_20240610

Division of Energy,Mineral, and Land Resources FOR AGENCY USE ONLY
o mu, Land Quality Section/Stormwater Program Year °atM �� Da,.
National Pollutant Discharge Elimination System (NPDES)
PERMIT OWNER AFFILIATION DESIGNATION FORM
(Individual Legally Responsible for Permit)
Use this form if there has been:
'11 C in f dili o ners i or facility , but the in•ivi ual
ho is le•all r s nsi#le for the ,er it h ch nee
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 C S N C G 0 7 0 0 4 9
2) Facility Information:
Facility name: Wilmington Gypsum Plant-River Road
Company/Owner Organization: Gold Bond Building Products LLC
Facility address: 838 Sunnyvale Drive
Address
Wilmington NC 28412
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
' Navigate to the "NPDES Industrial Program" section and run the Stormwater Permit
Contact Summary Report for your permit number.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Lance Davis
First MI Last
4) NEW OWNER AFFILIATION(legally responsible for the permit):
Person legally responsible for this permit: Todd D Broud
First MI Last
Page 1 of 2
Last revised 20 Feb 2022

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
VP-Manufacturing Operations&Engineering
Title
2001 Rexford Road
Mailing Address
Charlotte NC 28211
City State Zip
(704 ) 365-7691 [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.
. 1 2.2c }final si*sature (not t '
PERMITTEE CERTIFICATION:
I, Todd D Broud ,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.
6,(1o/Z©2
Signature Date
PLEASE SEND THE ORIGINAL SIGNED COPY OF THE COMPLETED
OWNER AFFILIATION CHANGE 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(919)707-9220 or visit the website
at:hup: ;deq.nc.gov..`s
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).
Page 2 of 2
Last revised 20 Feb 2022