NCG050420_Owner Affiliation Change_1/2/2019

Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
NZ National Pollutant Discharge Elimination System (NPDES)
Energy. Mineral & PERMIT OWNER AFFILIATION DESIGNATION FORM
L and Resour cgs r(Individual Legally Responsible for Permit)
FOR AGENCY USE. ONLY
Date R.e,vcd
Year Monil�
Day
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.
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 I I I I I N I C I G 1 0 1 5 I ()y 2 d
2) Facility Information:
Facility name: Pio'oe.rk Qiotch "CM.\ Coc 7csc n}son
Company/Owner Organization: (�pbes} eos(,il Too\ COc Poc a}scn
Facility address: \ri P,O \ndsoc. Cc er.\G Road,
Address
kAC- 200g2
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
http://deci.nc.gov/about/divisions/enerev-mineral-land-resources/enerev-mineral-land-permits/stormwatei-program
and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: N\ OAA ?� eh\ all ex
First MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
First MI Last
Pagel oft
S W U-0WNERAPFIL23March2017

NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
H�E S�eua\�S�
Title
1g00 "S c, dear. Ccee'L Ro cA
Mailing Address
L c co\ ton NC. 28092
City state Zip
(859)co`\l-9b`i�6 Ntco fie. Me. Qv eet)@bosch.can
Telephone E-mail Address
Far Number
5) Reason for this change:
A result of: ff Employee or management change
❑ Inappropriate or incorrect designation before
❑ Other
Ifotherplease explain:
...................................................................................................................
The certification below must be completed and signed by the permit holder.
PERMITTE�Ep CERTIFICATION:
I, Nl(l)IQ, �1(Q\ItC11 , 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. 1 understand that if all required parts of this form are not completed, this change may not be
processed.
clli�bs�bvlIv.2 LON
Signature VDate
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://deg ne gov/about/divisions/energv-mineral-land-resources/stonnwater
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S W U-O W NE RAF F IL-23Mar2017