NCG030075_Owner Affiliation Change Form_20171101

Division of Energy, Mineral, and Land Resources FOR AGENCY USE ONLY
Date Received
Land Quality Section / Stormwater Program Year Month Day
- National Pollutant Discharge Elimination System (NPDES)
Energy, Min era! & PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resources
ENVIRONMENTAL OUALITI (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 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
N C S N C G 0 3 0 0 7 5
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
BorgWarner
BorgWarner Turbo Systems
1849 Brevard Road
Address
Arden NC 28704
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
littp://deq.nc.gov/about/divisions/energy-mineral-land-resources/energy-mineral-land-permits/stormwater-pro,ram
and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Mike Doughtery
First MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
SWU-0WNERAFFIL-23March2017
Mark
First MI
Page 1 of 2
Passolt
Last

NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
Plant Manager
Title
1849 Brevard Rd
Mailing Address
Arden NC 28704
City State Zip
[phone] mpassolt(aborgwarner.com
Telephone E-mail Address
[phone]
Fax Number
5) Reason for this change:
A result of: ® 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.
PERMITTEE CERTIFICATION:
I, Mark Passolt, 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 n_ of completed, this change may not be processed.
11/1/2017
Signature
PLEASE SEND THE COMPLETED FORM TO:
Division of Energy, Mineral, and Land Resources
Stormwater Program
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
Date
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
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SWU-OWNERAFFIL-23Mar2017