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Home My WebLink AboutNC0004944_Owner Affiliation Change_20170203Permit Number: NC00 0 / 4 / 9 / 4 / 4 or NCG5 / / / / 1. Facility Name: Durafiber Technologies II. NEW OWNER/NAME INFORMATION: RECEIVEDINCDEQIDWR 1. This request for a name change is a result of: FEB 0 3 2017 a. Change in ownership of property/company Water Quality Permitting Section b. Name change only. X c. Other (please explain): Plant Manager Change 2. New owner's name (name to be put on permit): Fernando Montemavor 3. New owner's or signing official's name and title: Fernando Montemavor. (Person legally responsible for permit)_, Salisbury Plant Manager - (Title) 4. Mailing address: 7401 Statesville Boulevard City: Salisbury State: NC Zip Code: 28147 Phone: (704)639-2062: E-mail address: __Fernando. Montemayor(o)durafibertech.com THIS APPLICATION PACKAGE WILL NOT BE ACCEPTED BY THE DIVISION UNLESS ALL OF THE APPLICABLE ITEMS LISTED BELOW ARE INCLUDED WITH THE SUBMITTAL. REQUIRED ITEMS: 1. This completed application form 2. Legal documentation of the transfer of ownership (such as a property deed, articles of incorporation, or sales agreement) [see reverse side of this page for signature requirements] State of North Carolina I Environmental Quality I Water Resources 1617 Mail Service Center I Raleigh, NC 27699-1617 919 807 6300 919-807-6389 FAX https:Hdeq. nc. gov/about/divisions/water-resources/water-resources-permits/wastewater-branch/npdes-wastewater-permits NPDES Name & Ownership Change Page 2 of 2 Applicant's Certification: I, Fernando Montema or I , attest that this application for a name/ownership change has been reviewed and is accurate and complete to the best of my knowledge. I understand that if all required parts of this application are not completed and that if all required supporting information and attachments are not included, this application package will be returned as incomplete. Signature: Date: 0 L S I.201' THE COMPLETED A LICATION PACKAGE, INCLUDING ALL SUPPORTING INFORMATION & MATERIALS, SHOULD BE SENT TO THE FOLLOWING ADDDRESS: NC DEQ / DWR / NPDES 1617 Mail Service Center Raleigh, North Carolina 27699-1617 Version 712016 State of North Carolina Department of Environmental Quality Division of Water Resources EDMR REGISTRATION FORM Part A. PERMIT/FACILITY INFORMATION 1. NPDES Permit Number: N I CIO 10 10 14 19 14 14 I 2. Owner/Organization Name: Durafiber Technologies 3. Facility Name: Salisbury Plant 4. Facility's Physical Address: 7401 Statesville Boulevard City: Salisbury State: NC Zip Code: 28147 Part B. OWNER USER INFORMATION 1. Responsible Official's Name: Fernando Montemavor Title: Plant Manager (Owner or duly authorized representative) 2. Mailing Address: 7401 Statesville Blvd City: Salisbury State: NC Zip Code: 28147 3. Telephone Number: 704 - 639 - 2062 4. Email Address: Fernando.Montemavor@durafibertech.com 5. User ID (Assigned by NCDWR eDMR Administrator): Part C. USER ACCOUNT INFORMATION 1. Facility Administrator Permission The Facility Administrator user permission can be assigned at the time of registration by the NCDWR eDMR Administrator. If someone other than the Owner will be responsible for managing facility users within eDMR and you would like the Division to set up the permission at the time of registration, then please provide the user details for the individual who will need the Facility Administrator user permission. Note: If this person will be responsible for submitting eDMR reports, then you will also need to request Submitter permission for this user. In addition to the user details, please specify the permit number(s) to which the user will be associated. If additional space is needed, please make additional copies of the Facility Administrator User Details and complete as needed. 10141111I4M• A Ai William K. Mcdonald 704 - 642 - 2165 Bill.McDonald@durafibertech.co NC eDMR Registration Form (Revision 4.1) 2. Submitter Permission Provide the users, in addition to the Owner, who will need Submitter permission. The Submitter user permission can only be assigned by the NCDWR eDMR Administrator. The Owner specified above will be given full eDMR permissions including Submitter permission. In addition to the user details, please specify the permit(s) to which each user will be associated ,for eDMR submittal. Should additional space be needed for users and/or permits, please make additional copies of this page and complete as needed. NOTE. The Owner will be responsible for creating all facility users except those with Submitter permissions. In addition to the Owner and Submitter user groups, there are four user types identified by user permission level: Facility Administrator, Certifier, Data Entry and View Only. The Owner and Facility Administrator will have the ability to create and manage facility users. The Facility User Management Guide, located on the eDMR User Documentation web page, provides the appropriate procedures for facility user management. NC0004944 Bill K. Mcdonald 704 - 642 - 2165 n, BiILMcDonald@Durafibertech.co EmarP a� m wUserl D Assr nedi DWR eDM, R,Admrmstrdtor ' . )r; NC0004944 Sylvester Culbertson 704 - 642 - 2165 �� as � • ; Sylvester.Culbertson@durafibert�`UserDdl ech.Com o � p��,iD NC eDMR Registration Form (Revision 4.1) K RESPONSIBLE OFFICIAL AUTHORIZATION The Responsible Official, as identified in accordance with Part 11, Section B.11 of the Standard Conditions for NPDES Permits and 40.CFR 122.22, is the appropriate individual with the authority to sign applications or reports for the Owner/Organization. I, Fernando Montemayor (printed name), have the authority to make this request for Durafiber Technologies (Owner/Organization Name). REGISTRATION CERTIFICATION For the permit(s) associated with the Owner identified above, I request permission to submit DMR data using the NCDWR eDMR system. I understand that electronic submittal of the DMR does not fully satisfy US EPA's electronic signature requirements and as a result, I understand I will be required to print, sign, and submit hardcopies (one signed original and a copy) of the eDMR to NCDWR under the same reporting requirements as paper -based DMRs as specified in Part II, Condition D (2) of the NPDES Permit. I agree to protect the security of my user ID and password from compromise and shall take all necessary steps to prevent its loss, disclosure, modification, or unauthorized use. Fernando Montemayor Salisbury Plant Manager Owner/Responsible Official Name (type or print) Official Title (type or print) Az 0 :50.01-7 Owner/ R Bible Official Signature Date North Carolina General Statute § 143-215M provides that: 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; or who knowingly makes a false statement of a material fact in a rulemaking proceeding or contested case under this Article; or who falsifies, tampers with, or knowingly renders inaccurate any recording or monitoring device or method required to be operated or maintained under this Article or rules of the Commission implementing this Article, shall be guilty of a Class 2 misdemeanor which may include a fine not to exceed ten thousand dollars ($10,000). 18 U.S.C. Section 1001 provides a punishment by a fine or imprisonment not more than 5 years, or both, for a similar offense. NC eDMR Registration Form (Revision 4.1) January 31, 2017 Wastewater Branch Water Quality Permitting Section Division of Water Resources 1617 Mail Service Center Raleigh, NC 27699-1617 Subject: Delegation of Signature Authority DURAFIBER TECHNOOLOGIES NPDES Permit Number NC0004944 To Whom It May Concern: By notice of this letter, I hereby delegate signatory authority to each of the following individuals for all permit applications, discharge monitoring reports, and other information relating to the operations at the subject facility as required by all applicable federal, state, and local environmental agencies specifically with the requirements for signatory authority as specified in 15A NCAC 213.0506. Individual #1 Individual #2 (if applicable) Name:m '. William K. Mcdonald Sylvester Culbertson rtle a Technical Operator - Orc Maint Mechanic - Orc Backup 7401 Statesville Blvd 7401 Statesville Blvd Mailing Address: Salisbury Nc 28147 Salisbury Nc 28147 Physical Address. ` (if different) , '";' Sylvester. Culbertson@durafibertech. c Email Address Bill.McDonald@durafibertech.com . om OfficePhone: 704 - 642 - 2165 704 - 642 - 2165 Mobile kPh orie ;'h r; 336 - 905 - 1717 - - If you have any questions regarding this letter, please feel free to contact me at Fernando.Montemayor@durafibertech.com or 704-639-2062. SincYdo Fernntemayor Durafiber Technologies Salisbury Plant Manager 7401 Statesville Blvd, Salisbury, Nc 28147 Fernando.Montemayor@Durafibertech.Com 704-639-2062 cc: Select a region Regional Office, Water Quality Permitting Section �I��°I�l' +�i'ber Tecl�noloyie8 DuraFiber Technologies INVOICE 7401 Statesville Blvd. SHIPPING ORDER Salisbury, N.C. 28147 NO: 24294 DATE: 1 /31 /2017 SHIPPER TYPE: B SHIPPER SHIP TO: NCDEQ/DWR/NPDES 1617 MAIL SERVICE CENTER Originator: HAWKINS 7046422104 CostCenter: 0712 Phone Ext: Ship From Location: SALISBURY RALEIGH NC 27699 USA "SElement: Acct: Attn: PO No: B36512 Phone: Ext: Requisition: ITEM DESCRIPTION QUANTITY UNIT PRICE AMOUNT FEB 0 3 2017 Water Quality ACTION TO BE TAKEN: REASON: Per RZ1119SPutfuls PACKING LIST------------------