NCG070011_Owner Affiliation Change_20180510

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, Mineral & PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resources
(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 rill 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�G.. 0 7 0 0 1 1
2) Facility Information:
Facility name: Lenox Corporation
Company/Owner Organization:
Facility address: 1800 Dobbs Farm Rd.
Address
Kinston NC 28501
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
littp:Hdeg.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: Paul Leichtnam
First MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
� s 1eegany'i'Issponsible for this permit: Bob Lupica
MAY 10 2018 First MI Last
DENR-LAND QUALITY Page 1 of 2
&TVRI WLZ"E WN4WW17

NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
VP of Manufacturing
Title
1800 Dobbs Farm Rd.
Mailing Address
Kinston NC 28501
City Q3aa- State Zip
( LCL 559-t.3,6 uuu_luPlca�W'le[1UX.cutn
Telephone E-mail Address
(/-z)/- ) 669--7X2
Fax Number
5) Reason for this change:
Q 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 Bob Lupica , 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.
4/25/18
Sig ture
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
RECEIVED
MAY 10 2014
S W U-OWNERAF FILr23Mar2017 Page 2 of 2 DENR-LAND QUALITY
STORMWATER PERMITTING