NCS000370_Permit Owner Affiliation Designation_20190722

Energy. Mineral &
Land Resources
ENVIRONMENTAL DUAL It Y
Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
FOR AGENCY USE ONLY
Date Received
Year
Month
Day
National Pollutant Discharge Elimination System (NPDES)
PERMIT OWNER AFFILIATION DESIGNATION FORM JUL 2 2 2019
(Individual Legally Responsible for Permit)
Use this form if there has been: STCRMWATER PERMiTTING
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 0 0 0 13 1 N I C I G
2) Facility Information:
Facility name: Bridgestone America's Tire Operations, LLC
Company/Owner Organization: Bridgestone America's Tire Operations, LLC
Facility address: 3001 Firestone Pkwy, NE
Address
Wilson NC 27893
City State zip
To find the current legally responsible person associated with your permit, go to this website:
http: Hdeg.nc. gov/about/divisions/energy-mineral-land-resources/energy-mineral-land-permits/stormwater-program
and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Mitch
E Burke
First MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: Vergil Norrod
Page 1 of 2
First MI Last
S W U-OWNERAFFIL-23March2017

NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
5) Reason for this change:
A result of:
If other please explain:
Plant Manager
Title
PO Box 1139
Mailing Address
Wilson NC 27894
City State Zip
( 252 ) 246-7766 [e-mail]
Telephone E-mail Address
Fax Number
❑ Employee or management change
❑ Inappropriate or incorrect designation before
❑ Other
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
I Vergil Norrod , 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.
Vic_ O,✓� __r 715=,l?
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://dey.nc.gov/about/divisions/energy-mineral-land-resources/stonnwater
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S WU-OWNERAFFIIr2 War2017