NCG030656_Name Ownership Change_20180711

State of North Carolina ;I D ��
Department of Environment and Natural Resources
Division of Water Quality
STATE STORMWATER PERMIT NAME/OWNERSHIP CHANGE FORM
I. CURRENT PERMIT INFORMATION
1. Stormwater Management Permit Number: C—> EneFa w IYLi
2. Project Name: 4�5m LLILO-S- %VOL /'AL,
3. Current Permit Holder's Company Name/Organization: 7�6ti CST06 S We, JOS
4. Signing Official's Name: v�QN�L �� Title:
5. Mailing Address: // 2,' 2_1Z2/�
%C "aj Y
City: ��'� e466 State: /%, e) Zip:
6. Phone: �G -7S - Fax: (70q) 3IZ) 0r)t i
II. PROPOSED PERMITTEE / OWNER / PROJECT / ADDRESS INFORMATION
This request is for: (please check all that apply)
[✓Name change of the owner (Please complete Items 1, 2 and 3 below)
❑ Name change of project (Please complete Item 5 below)
❑ Change in ownership of the property/company (Please complete Items 1, 2, 3,
❑ Mailing address / phone number change. (Please complete Item 4 below)
❑ Other (please explain):
and 4 below)
1. Proposed permittee's company name/organization: P)S/' G?L4Yn,'S Z S,� 11.6
2. Proposed permittee's signing official's name: ff)al-k, Ce/&C�
3. Proposed permittee's title: OZ�,a,�2CJ
4. Mailing Address:
City:
Phone: (
5. New Project Name to be placed ort permit:
State: Zip:
Fax:
Please check the appropriate box. The proposed permittee listed above is:
❑ HOA or POA (Attach documentation showing that the HOA or POA owns, controls, or has a
recorded easement for all areas that contain stormwater system features. Print name of HOA or
P in #1 above and provide name of HOA/POA's authorized representative in #2 above)
he property owner
❑ Lessee (Attach a copy of the lease agreement and complete Property Owner Information on
page 4)
❑ Purchaser (Attach a copy of the pending sales agreement. Final approval of this transfer will be
granted upon receipt of a copy of the recorded deed)
❑ Developer (Complete Property Owner Information on page 4)
RECEIVED
APR 2 6 2016
SSW N/O Change Rev24Sept2012 Page 1 of 4 DENR-LAND QUALITY
STORM&TER PERMITTING

III. REQUIRED ITEMS
A request to transfer a permit will not be approved by the Division of Water Quality (DWQ) unless all
of the applicable required items listed below are included with the submittal. Failure to provide the
listed items may result in processing delays or denial of the transfer.
1. This completed and signed form. This certification must be completed and signed by both the
current permit holder and the new applicant if this is a change of ownership.
2. Legal documentation of the property transfer to a new owner.
3. A copy of any recorded deed restrictions, covenants, or easements, if required by the permit.
4. The designer's certification (DWQ Engineer and Designer Certification Forms are available from
each DWQ Regional office), if required by the permit and if not already submitted to DWQ.
5. If the proposed permittee is a firm, partnership, association, institution, corporation, limited liability
company, or other corporate entity, provide documentation showing the authority of the named
representative to act on behalf of the proposed permittee.
6. The $40.00 processing fee. If this is an initial transfer from the original permittee the processing
fee is not required. Subsequent ownership transfers will require the $40.00 processing fee.
IV. CURRENT PERMITTEE'S CERTIFICATION
Please check one of the following statements and fill out the certification below that statement:
Check here if the current permittee is only c a g hi r/its name, the project name, or mailing
address, but will retain the permit. I, ✓, the current
permittee, hereby notify the DWQ that I arrc an Inga and/or I am changing my mailing
address and/or I am changing the name of the permitted project. I further attest that this application
for a name/ownership change is accurate and complete to the best of my knowledge. I understand
that if all required parts of this application are not completed or if all required supporting information
and attachments listed above are not included, this application package will be returned as
incomplete.
❑ Check here if current permittee is transferring the property to a new owner and will not retain
ownership of the permit.
I, , the current permittee, am submitting this application
for a transfer of ownership for permit # . I hereby notify DWQ of the sale or
other legal transfer of the stormwater system associated with this permit. I have provided a copy of
the most recent permit, the designer's certification for each BMP, any recorded deed restrictions,
covenants, or easements, the DWQ approved plans and/or approved as -built plans, the approved
operation and maintenance agreement, past maintenance records, and the most recent DWQ
stormwater inspection report to the proposed permittee named in Sections II and V of this form. I
further attest that this application for a name/ownership change is accurate and complete to the best
of my knowledge. I understand that if all required parts of this application are not completed or if all
required supporting information and attachments listed above are not included, this application
package will be returned as incomplete. I assign all rights and obligations as permittee to the
proposed permittee named in Sections II and V of this form. I understand that this transfer of
ownership cannot be approved by the DWQ unless and until the facility is in compliance with the
permit.
Signature: ✓ Date:
I,�i5 ti f1pl� , a Notary Public for the State of
U f1Gr , County of 0 r\ C� , do hereby certify that
Y1Aw- Y, rood 1-t" ti personally appeared before me this the
I � day of -p-O-) , 20 ! 8 , and acknowledge the due execution of the
forgoing instrument. Witness my hand and official seal,
Nota y Si ature
SSW N/O Change Rev24Sept2012 Page 2 of 4
(Notary Seal)
KRISTY MAYNOR
Notary Public, North Carolina
Cleveland County
My Commission Expires
August 21, 2019

KSM Castings Group
KSM Castings USA Inc.
u
Castings
04/19/2018
State of North Carolina
Division Of Environment and Natural Resources Division
1617 Mail Service Center
Raleigh, NC 27699 - 1617
Reference: Statement of Ownership
KSM Castings USA Inc.
Shelby, North Carolina
Dear Sir,
This letter has been prepared to advise the Division Of Environment and Natural
Resources Division of Water Quality in regarding a change in owner for reporting
information.
Our New Plant Manager / President is Mark Bradley.
Should you have any questions or require additional infomration please contact me at
704-466-0065 or by e-mail at [e-mail]. I look forward to
working with you in the future regarding our waste water permit.
Sincerely
Keith Weaver
EHS Manager
KSM Castings USA Inc.
120 Blue Brook Drive Internet: www.ksmcastings.com
(formerly: Brook
Plato Lee Road) E -Mail: info OWsmcastings.com
Telephone: [phone]
Shelby, NC 28150