NCG030012_Owner Affiliation Change_10/25/2018

Division of Energy, Mineral, and Land Resources FOR AGENCY USE ONLY
Dale RccLand Quality Section / Stormwater Program Ycar oath
Da
K, National Pollutant Discharge Elimination System (NPDES)
l=nergy Mineral & PERMIT OWNER AFFILIATION DESIGNATION FORM
Lana Resources
EHriROHMEHf4L d�A4rtr (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.
I) 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:
(0 r) Certificate of Coverage
N I C I G 10 13 10 0 'i 2
Magneti Marelli Powertrain USA Inc.
Magneti Marelli Powertrain USA Inc.
2109 Nash Street
Address
Sanford NC 27330
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
htW:/Ideg.nc.aoviabout/divisions,`ener = mineral -1 n -resources/ener -mineral-land- ermilslstortnwater- ro am
and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Lloyd
First MI
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
S WU-OWNERAFFtir23March2017
Smith
Last
Stefano Verdiani
First MI Last
Page 1 of 2

NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
Plant Manager
Title
2101 Nash Street
Mailing Address
Sanford NC 27330
city state zip
( 910 ) 303-7326 [e-mail]
Telephone E-mail Address
r 919 1775-6432
Fax Number
5) Reason for this change:
A result of El
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:
I, `-jV"L2n0attest 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 ICS - -z-S-tA
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: deco.nc.l;oviabout/divisions'energy-mineral-land-resources/stortnwater
Page 2 of 2
S W U-OWNERAFFILr23Mar2017