NCG050399_Owner Affiliation Designation Form_20180419

UPM
The Biofose
Company
DEMLR — Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
April 186, 2018
Re: Permit Owner Affiliation Designation Form
Dear Sir or Madam:
We are submitting the Permit Owner Affiliation Designation Form to update a contact. The
legally responsible person for the UPM Raflatac Cane Creek Facility (NCG050399) is now
Brandon Baertschi instead of Laura Cummings.
This form was also submitted electronically on 0411812018.
Please contact me at [phone] or [e-mail] if you have any
questions.
Sincerely,
Brandon Baertschi
Safety, Health, Environment Manager
Attachments
UPM RaFlatac, Inc.
400 Broadpointe Drive
Mills River, NO 28759
USA
Tel. [phone]
Toll Free [phone]
Fax [phone]
Toll Free Fax [phone]
www.upmra8atac.com
RECEIVED
APR 19 2098
DENR-LAND QUALITY
STORMWATER PERMITTING

Division of Energy, Mineral, and Land Resources FOR AGENCY USE ONLY
Date Received
Land Quality Section 1 Stormwater Program Year Month Da
National Pollutant Discharge Elimination System (NPDES)
Energy, Mineral & PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resources
ENVIRONMENTAL GLALITY (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:
RECEIVED
• the responsible corporate officer (for a corporation);
• the principle executive officer or ranking elected official (for a municipality, state, fedeAHR a r �Oiac
agency);
• the general partner or proprietor (for a partnership or sole proprietorship); bENR-LAND QUALITY
• or, the duly authorized representative of one of the above. STORMWATER PERMITTING
1) Enter the permit number for which this change in Legally Responsible Individual ("Owner Affiliation")
applies:
Individual Permit (or) Certificate of Coverage
N IC ISI I I I INICIG10 15 10 13 9 9
2) Facility Information:
Facility name: UPM Raflatac Cane Creek Facility
Company/Owner Organization: UPM Raflatac, Inc.
Facility address: 280 Cane Creek Rd.
Address
Fletcher NC 28732
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
htt :llde .nc. ov/about/divisions/ener -mineral-land-resources/ener -mineral-land- ermits/stNW D
and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed: APR 19 2018
DENR-LAND QUALITY
Previous legally responsible individual: Laura CummUTRIVIWATEFR PERMITTING
First Ml Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: Brandon Baertschi
First M1 Last
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S WU-OWNERAFFIlr23March2017

NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
EH5 Manager
Title
400 Broadpointe Dr.
Mailing Address
Mills River NC 28759
City State Zip
ii Imo) q lti-t5�� Urc1flUUll.Ue1CR5[;f11�UI,)fTl.t:V[a -
Telephone E-mail Address
(OZO ) oD 1-40ou
Fax Number
5) Reason for this change:
A result of Q 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, Brandon Baertschi '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.
04/18/18
Signature Date
PLEASE SEND THE COMPLETED FORM TO:
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
For more information or staff contacts, please call [phone] or visit the website
at: http://deg.nc.gov/about/divisions/energy-mineral-land-resources/stormwater
Page 2 of 2
S WU-OWNERAFF0r23Mar2017