NCG090006_Owner Affiliation Change_20180926

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, tifinerni& PERMIT OWNER AFFILIATION DESIGNATION FORM
Lund Resotirces
t H V IRUNI-IF,141 1IU A L I I I (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:
• 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 I C I S FEI N I C G 10 19 10 10 10 6
2) Facility Information:
Facility name: Mallard Creek Polymers. Inc.
Company/Owner Organization:
Facility address: 2800 Morehead Road
Address
Charlotte NC 28262
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
htt ://d .ne. ov/about/divisi0ns/ener -mineral-land-resources/ener -mineral-land- ermits/stormwater- ro rarn
and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Scot Whyte
First MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: Duane Harris
First MI
Page 1 of 2
S WU-OWNERAFFIL-2Warch2017
Last

NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
Plant Manager
Title
2800 Morehead Road
Mailing Address
Charlotte NC 28262
City State Zip
. � 70 y) S 41- 06L2 c�dnr�l?, hutr�'S [� rt'►arQol ym��, �,rl
Telephone E-mail Address
(7 aq) sy 7 - gs q9
Fax Number
5) Reason for this change:
❑✓ Employee or management change
A result o£ ❑ 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 Duane Harris , 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.
1
gnature 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://der.nnc.gov/about/divisions/energy-mineral-land-resources/stonnwater
Page 2 of 2
S W U -O WNE RAF F ILr23 Ma r20 l 7

NC Division of Energy, Mineral and Land Resources
NPDES Stormwater Permit Contacts Summary
NC DEMI.lt lists the following contact information in our Permit Database for your permit as of ).12612filK
Permit Number: NCGO90006
Permit Type: Paints, Varnl5he5, Lacquers 5t0rmwater Q[5charge_COC
Facility Name: Mallard Cregk Polymers Incorporated
Facility Addressl: 2800, Morehead Rd
Facility Address2:
City, State & Zip: hdrlljft. NC 28262
Owner Information Details:
MUST submit a Change of Name/Ownership form to DEMLR to make any changes to this Owner information.
(Click Here for " h
Owner Name: MaLL2L Creek PnivmeFjjLty
Owner Type: 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.)
Owner Affiliation: .0 o t1l e- r r S Title: /ail �/Vao" 41
Addressl: 2800 Morehead Rd I J
Address2:
City, State & Zip: Charlotte. NC 28262
Work Phone: [phone] Fax: [phone]
Email Address: swhvte(almrWymers.cam
*** Permit Annual Fee Billing ***
Billing Month: January
Invoice Number Invoice Date Invoice Due Date
Owner Contact Person(s)
Contact Name Title Address
Facility Contact Person(s)
Invoice Amount Invoice Status
Phone Fpx mil
Contact Name Title Address Phone Fax Email
�%r�eLlf�' l�cer7� S
SGpi_]A /011 AVI-✓/c{ 2800 Morehead Rd, Charlotte, NC 28262 704-547-0622 704-547-8849 6wgyfe@mcpolymers
r Fr J .com
Permit Contact Person(s)
Contact Name Title Address Phone Fpx Eflai1
iia ve- 7 dV-8f? 7 -9'1 5 v J"4/? � a//j'zIfy&
Permit Billing Contact
Contact Name Title Address
,.Seot-Wffy-fe---4 F PS ,416, 2800 Morehead Rd, Charlotte, NC 28262
Phone Fax Email
704-5 - 69- �r
Elt,-10M
Paye