NCG170366_Owner Affiliation Change_20181113

Division of Energy, Mineral, and Land Resources FOR AGENCY USE ONLY
Date Received
Land Quality Section / Stormwater Program Year Porith I Day
K, National Pollutant Discharge Elimination System (NPDES)
Energy, Mineral & PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resources
ENVIRONMENTAL QUALITY (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:
NOV 112018
2018
• the responsible corporate officer (for a corporation); DENR-LAND QUALi7y
• the principle executive officer or ranking elected official (for a municipalitPTQRlift*xtR-�gublic
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 N I C I GM 7 0 13 16 T6
2) Facility Information:
Facility name: Abercrombie Textiles LLC
Company/Owner Organization: Abercrombie Textiles LLC
Facility address: 3400 US Highway 221A (PO Box 427)
Address
Cliffside NC 28024
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
http://deg.nc. cov/about/divisions/ener,y-mineral-land-resources/ener,-v-mineral-land-permits/stormwater-program
and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Earl Holland
First MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: Phillip D Freeman
First MI Last
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S WU-OWNERAFFIL-23March2017

NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
Manufacturing Manager
Title
PO Box 427
Mailing Address
Cliffside NC 28024
City State Zip
( 828 ) 202-5813 [e-mail]
Telephone E-mail Address
x828 1657-1639
Fax Number
5) Reason for this change:
El 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 John G. Regan , 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
PLEASE SEND THE COMPLETED FORM TO:
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
Date
For more information or staff contacts, please call [phone] or visit the website
at: http://deg_nc.gov/about/divisions/energy-mineral-land-resources/stoi-mwater
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S WU-OWNERAFFIL-23Mar2017