NCG090006_Owner Affiliation Change_20190603

Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
Energy. "ineral & PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resources
N VIRONMEN'l A L U UA UYY (Individual Legally Responsible for Permit)
Use this form if there has been:
FOR AGENCY USE ONLY
Date Received
Year
Montle
Day
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 I I I I I I I I N I C I G 1 0 1 9 0 1 0 0 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:
http:/Idea.nc.gov/about/divisions/energy-mineral-land-resources/energ_y-mineral-land-permits/stormwater- ro ram
and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Duane Harris
First MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: Marc Bumgai
First MI Last
Page I of 2
SWU-OWN ERAFF I L-23March2017

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
[phone] [e-mail]
Telephone E-mail Address
[phone]
Fax Number
5) Reason for this change:
A result o£ ® 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, N,C , attest that this application for this change in Owner Affiliation
(person legally responsib4 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.
Signa
(13119
PLEASE SEND THE COMPLETED FORM TO:
Division of Energy, Mineral, and Land Resources
Stormwater Program
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://deq.ne gov/about/divisions/energy-mineral-land-resources/stormwater
Page 2 of 2
SW U-OW NERAFFI L-23Mar2017

NC Division of Energy, Mineral and Land Resources
NPDES Stormwater Permit Contacts Summary
NC DEMLR has the rollowint=_ contact information in our Permit I)atnhaw for your ncrmit :n or6f312019
Permit Number:
NCG090006
Permit Type:
Paints, Varnishes. La�gu rmw r Di name COC
Facility Name:
Mallard Creek Polymers InCor
orated
Facility Addressl:
2800 Morehead Rd
Facility Address2:
City, State & Zip:
Charlotte. NC 28262
i9wnerinformation
Details:
MUST submit a Change of Name/Ownershipfolm to DEMLR to make any changes to this Owner information.
(Qck Here far "change of Name/pw►rer�[frp" �prry,f
Owner Name:
Mallard Creek Polymers Inc
Owner Type:
Non vgrnmg<nt
Owner Type Group: Owniration
*** 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:
Qua ao klarrk M a�C
Q /,� cl cw!'/ia r Title: Plant Manager
Addressl:
2800 Morehead Rd
/
Address2:
City, State & Zip:
Charlotte, NC 28262
Work Phone:
704-547-0622
-Fax: [phone]
Email Address:
�drrely4la"AQn
*** Permit Annual Fee Billing ***
Billing Month:
January
Invoice Number
Invoice Date
Invoice Due Date Invoice Amount Invoice Status
Owner Contact Person(s)
Contact Name
Title
Address Phone Fax
Email
Facility Contact Person(s)
Contact Name
Title
Address Phone Fax
Email
lluaaa Harris—
Plant Manager
2800 Morehead Rd, Charlotte, NC 28262 704-547-0622 704-547-8849
dq lanis�m poly
IL404-e ra�i�crtttf
mers.com
Permit Contact Person(s)
Contact Name
Title
Address Phone Fax
Email
Dave Haley
EHS Manager
2800 Morehead Rd, Charlotte, NC 28262 704-887-9450 704-547-8849
dhaley@mcpolymers
.corn
Permit Billing Contact
Contact Name
Title
Address Phone Fax
Email
Dave Haley
Ir 1aS /0 t
2800 Morehead Rd, Charlotte, NC 28262 704-887-9450 704-547-8849
dhaley@mcpolymers
.corn
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