NCG050101_Owner Affiliation Change Form_20180601

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NCDENK
Nc CA OLINA OEPA EN of
E VIRONMe_ ANP NAr AL RESoumRG
Division of Energy, Mineral and Land Resources FOR AGENCY USE ONLY
Date Received
Land Quality Section / Stormwater Permitting Program Year Month Day
National Pollutant Discharge Elimination System (NPDES)
PERMIT OWNER AFFILIATION DESIGNATION FORM
(Individual Legally Responsible for Permit)
if NO CHANGE in company or facility ownership or name has occurred.
If a Name Change and/or Ownership Transfer at the facility has prompted this change, do
NOT use this form. You must fill out the Name -Ownership Change Form and provide all
necessary supporting documentation instead.
1) Enter the permit number for which this change in Legally Responsible Individual ("Owner
Affiliation") applies:
Individual Permit
N I C I S
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
(or) Certificate of Coverage
N C I G Q 1 b707 [ d E
Ormn 6 c I I LA -L
It rn e,
loo4 el-ble.r To,c
Address
Condv�?,r Kc 2�'U+3
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
h :ll ortal.nedenr.or web/Ir/sw- ermit-contacts and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: 1 r l i L ��� t° i H Z Ll ry-� b rtA n n6 n
First MI Last
4) NEW OWNER AFFILIATION (Legally responsible for the permit):
Person legally responsible for this permit: L -a r V- Ll
First Mr Last
Imo- l a n -� m a -l- G1 A e r
Title "
lobo- r-e-iSGer eonci
Mailing Address
Con6vtr- N(21 2Bi�t3
City State Zip
cS��) 4bq-6M x rk+ayn rrwrt),t4i.coUA
Telephone E-mail Address arm a[.ei m
c } no - ax
Fax Number
Page 1 of 2
5 W U -OW N E RAFT L-22 Ma y2014

NPDESStormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
5) Reason for this change:
A result of
If other please explain:
What does "legally responsible person" mean?
That person is either:
0/ Employee or management change
❑ Inappropriate or incorrect designation before
❑ Other
• 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 that person above.
The certification below must be completed and signed by the permit
holder.
PERMITTEE CERTIFICATION:
]%
I, `` ay-&-� m D b r6 , 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.
�j
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 visit our website:
htt :// ortal.ncdenr.or web/lr/stonnwater
Page 2 of 2
8WU-0WNERAFF1L-22May2014

NC Division of Energy, Mineral and Land Resources
NPDES Stormwater Permit Contacts Summary
NC DEMLR has the following contact information in our Permit Database for your hermit as of 5/31/2018.
Permit Number: NCGO50101
Permit Type: Apparel/Printing/Paper/Leather/Rubber Stormwater Discharge COC
Facility Name: Armacell LLC -Conover Plant
Facility Addressl: 1004 Keisier Rd
Facility Address2:
City, State & Zip: Conover, NC 28613
Owner Information Details:
MUST submit a Change of Name/Ownership form to DEMLR to make any changes to this Owner information.
(Mick Here for Change of Name/Ownership"Form)
Owner Name:
Owner Type:
Owner Affiliation:
Addressf:
Address2:
City, State & Zip:
Work Phone:
Email Address:
Armacell LLC
Non -Government
Owner Type Group: Organization
*** Legally Responsible for Permit ***
(Responsible corporate officer/principle executive officer or ranking elected official/general partner or proprietor,
or any other person with delegated signatory authority from the legally responsible person.)
Michael H Zumbrunnen
7600 Oakwood St Ext V 11016
r O-10 4
V 1
Mebane, NC 27302
919-304-8664
michael.h.zumbrunnen0armacell.com
*** Permit Annual Fee Billing ***
Billing Month: May
Title:
Fax:
Invoice Number Invoice Date Invoice Due Date Invoice Amount Invoice Status
Owner Contact Person(s)
Contact Name Titlee+ Address IOC) � Af n6i'eY OXa Phone Fax (Email
Alike--Fahsel X600-©ak Wood-5t-Exention,-Mebanz, 91-9 3,84=3846' . CU A 0arm l 6e i f
N&27303=4577 ( o DV e - V - 1J & ZV & 13 q Ei-36 4 - 39 4
i�
Tem -Himmel � e '-h No Y'w 60'1 � 7698.8ekwmd St,.a4®baee��3fi}2 7' 9] 9-364 3846 � «,,-//�3-&'i 3� e4 & )( 10 17- o D
Facility Contact Person(s) 6,J VI scorn CCy`ker Pr, efytCel (- ! 1, Ne F 6� k , A. Norw00&ftrh,iCel l�
Contact Name Title Address Phone (�r]5 I Fax Email
L-&rw. puch
Jose /� l r f f / 1004 Keisler Rd, Conover, NC 28613 828-464-5880 Jas® @Ar
Nel �f r�i vV' �` Y Ext. -3-1.89' { 7- / 0 6 0 macell.com
LD(ACht)
Permit Contact Person(s) ce1�vlLf G>° i i ,Gb rn
Contact Name Title Address Phone Fax Email
SO -Me, &15 f oAcc' h',� co y,&a c: pef-5oh
Permit Billing Contact
Contact Name Title Address Phone Fax Email
0"d-c'nx- ta e. r l b U r�' 1004 Keisier Rd, Conover, NC 28613 W _q [p u _6 f �b y j Z [ R 0Q
VLat-th. -F. mare
5/31/2018 Gl.i'►' -i Ge[ I . I&M Page 1