NCG030039_Owner Affiliation Change_20171031

DAIMLER
Lindsey Speed
Sr. Environmental Engineer
Daimler Trucks
11550 Statesville Blvd
Cleveland, NC 27013
704 645 5353 Phone
October 25, 2017
Division of Energy, Mineral, and Land Resources
Stormwater Program
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
To whom it may concern:
Please find enclosed Permit Owner Affiliation Designation Form for Daimler Trucks North
America LLC - Cleveland Truck Plant.
Should you have any questions, please contact me at 704-645-5353 or
[e-mail].
Sincerely,
Daimler Trucks, LLC
X-P/�
Lindsey Speed
Sr. Environmental Engineer
Enclosures

Division of Energy, Mineral, and Land Resources FOR AGENCY USE ONLY
Date Received
Land Quality Section / Stormwater Program Year Month Day
.i
- National Pollutant Discharge Elimination System (NPDES)
Energy, Mineral & PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resources
ENVIRONMENTAL QUALITY (Individual Legally Responsible for Permit)
Use this form if there has been:
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 aName-Ownership Chan For
and submit the completed form with all required documentation. N V j:�
Pnf7
What does "legally responsible individual" mean?
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The person is either: ' ' n-1_.�I,,VJ
• the responsible corporate officer (for a corporation);
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• 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
N I c I S I I I I N I c I G I p'Z 10103`1
2) Facility Information:
Facility name: -Du\M\&Y' 1fLk6U 000\0 PWA&i Ulk UL-C1ey?luY%d
Company/Owner Organization: 'bAkV\,\VY 'C`n1(-" T401r*n PV -At% -!(A Z.I.
Facility address: \\C, -G0 �k*tSy`1ft V\J4
Address
Qegtbak1 N G 91013
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
llttp://deq.nc. izov/about/divisions/enemy-mineral-1and-resources/energy-mineral-land-permits/stormwater-program
and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: UW11'b d L Mcwyrq
First MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
S W U -O WNERAFF ILr23 March2017
1kxminq 10 ?Yur►f
FiW MI Last
Page 1 of 2

NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
1?k-ky* M-mymoa er'
Title
\\s5o &"kSV1\1't 81vd
Mailing Address
Ck"ekray.) NC. 1-10 13
City State Zip
ON )(oy5-5'100 kneAnina.p.brwytSetiz rt kv.L0fn
Telephone E-mail Adress
OULA ) tP 4s— S40D
Fax Number
5) Reason for this change:
[Employee or management change
A result of: ❑ Inappropriate or incorrect designation before
❑ Other
If other please explain:
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
I, 10X1 run , attest that this application for this change in Owner Affiliation
(person legally r ponsible 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.
l� �fl �
i ature Date
PLEASE SEND THE COMPLETED FORM TO:
Division of Energy, Mineral, and Land Resources
Stormwater Program
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
For more information or staff contacts, please call [phone] or visit the website at:
http://deq.nc. gov/about/divisions/energy-mineral-land-resources/stormwater
Page 2 of 2
S WU-OWNERAFFIIr23Mar2017