NCG070007 -

Are -F*WA
A . 0 a
NC®ENR
NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT ANO N/ URA RE50URCE5
Division of Energy, Mineral and Land Resources FOR AGENCY USE ONLY
Date Received
Land Quality Section / Stormwater Permitting Program Year Mond, Day
National Pollutant Discharge Elimination System (NPDES)
PERMIT OWNER AFFILIATION DESIGNATION FORM
(Individual Legally Responsible for Permit)
Use this form if there has been:
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
N C S
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
(or) Certificate of Coverage
N I C I G 1017101010171
Pilkington NA (North America)
13121 S. Rocky Ford Road
Address
Laurinburg NC 28352
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
http://portal.ncdenr.org/web/Ir/sw-permit-contacts and run the Permit Contact Summary Report.
3) OLID OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Christopher J.
First MI
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
SW U -OWN ERAFFI L-25July2014
Christopher J.
DeCerbo
Last
Miller
RECEIVED First MI Last
MAR 20 2016 Page I of 2
DENR-LAND QUALITY
STORMWATER PERMITTING

NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
Plant Manager
Title
131215. Rocky Ford Road
Mailing Address
Lourinburg NC 28352
City State Zip
( 910) 277-2103 [e-mail]
Telephone E-mail Address
( )
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:
1, Christopher Miller , 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.
3 l3 /�
Signature Date
PLEASE SEND THE COMPLETED FORM TO:
Division of Energy, Mineral and Land Resources
Stormwater Permitting Program
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:
http://portal.ncdenr.org/web/Ir/stormwater
Page 2 of 2
SWU-0WNERAFFIL-25July2014