NCG030427 - GKN Driveline - Mebane

��.
Division of Energy, Mineral & Land Resources FOR AGENCY USE ONLY
��-
Land Quality Section/Stormwater Permitting Date Received
L Q ,� g Year I Month Day
NCDENR
National Pollutant Discharge Elimination System
Nauru CAROLINA D- of
E -0 --ANO NNURAL RESOURCES
PERMIT NAME/OWNERSHIP CHANGE FORM
I. Please enter the permit number for which the change is requested.
NPDES Permit
(or) Certificate of Coverage
C 1 'S 116 1 1 1
N 1 G 1 G, 10 13 10 14 12 1 7
II. Permit status miff to requested change.
a. Permit issued to (company name):
GKN Driveline
b. Person legally responsible for permit:
Zach Breenhaw
First MI Last
^' CF—WED
Title
1067 Trollingwood-Hawfields Rd
FEB
FEB 0 2 2018
Permit Holder Mailing Address
Mebane NC 27302
DENR-LAND QUALITY
City State Zip
8T0R11911I1AT" RpEpj ITMG
[phone] ( )
Phone Fax
c. Facility name (discharge)
GKN Drive/Alamance
d. Facility address:
1067 Trollingwood-Hawfields Rd
Address
Mebane NC 27302
City State Zip
e. Facility contact person:
Zach Breenhaw [phone]
First / MI /Last Phone
III. Please provide the following for the requested change (revised permit).
a. Request for change is a result of:
❑ Change in ownership of the facility
Name change of the facility or owner
If other please explain: Change in contacts
b. Permit issued to (compa
c. Person legally responsible for permit:
Michael Graham
First MI Last
Plant Director
Title
1067 Trollingwood-Hawfields Rd
Permit Holder Mailing Address
Mebane NC 27302
City State Zip
[phone]
Phone E-mail Address
d. Facility name (discharge):
e. Facility address:
Address
City State Zip
f. Facility contact person:
Richard Szilvay
First MI Last
[phone] Richard.szilvay(a gkndrivelme.com
Phone E-mail Address
IV. Permit contact information (if different from the person legally responsible for the permit)
Revised Jan 27. 2014

NPDES PERMIT NAME/OWNERSHIP CHANGE FORM
Page 2 of 2
Permit contact: Matthew P Herman
First MI Last
Ehs Coordinator
Title
1067 Trollingwood-Hawfields Rd
Mailing Address
Mebane NC 27302
City State Zip
[phone] matthew.herman(a�,gkndriveline.com
Phone E-mail Address
V Will the permitted facility continue to conduct the same industrial activities conducted prior
to this ownership or name change?
® Yes
❑ No (please explain)
V1Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS
ARE INCOMPLETE OR MISSING:
❑ This completed application is required for both name change and/or ownership change
requests.
❑ Legal documentation of the transfer of ownership (such as relevant pages of a contract deed,
or a bill of sale) is required for an ownership change request. Articles of incorporation are
not sufficient for an ownership change.
.......................................................................................................................
The certifications below must be completed and signed by both the permit holder prior to the change, and
the new applicant in the case of an ownership change request. For a name change request, the signed
Applicant's Certification is sufficient.
PERMITTEE CERTIFICATION (Permit holder prior to ownership change):
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 is not included, this application package will be
returned as incomplete.
Signature
Date
uANT CERTIFICATION
attest that this application for a name/ownership change has been reviewed and is accurate and
complete to the best of my know] ge. I understand that if all required parts of this application are not
completed and that if all requi supporting information is not included, this application package will be
ret Zed as inc nplete.
Signature Date
PLEASE SEND THE COMPLETE APPLICATION PACKAGE TO:
Division of Energy, Mineral and Land Resources
Stormwater Permitting Program
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
Revised Jan 27. 2014