NCS000373_Owner Affiliation Change_20201124

Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
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PERMIT OWNER AFFILIATION DESIGNATION FORM
E 4VIfU1NICI:17fAI aUi.l i1Y
(Individual Legally Responsible for Permit)
Use this form if there has been:
FOR AGENCY USE ONLY
Date Received
Yenr
iVonth Ony
NO CHANGE in facility ownership or facility name, but the individua�
r is legally responsiblethe 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 cither:
• 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 itttrnber for which this change in Legally Responsible Individual ("Owner Affiliation")
applies:
Individual Permit
N` C IS. a 10 10 13 17 13
2) Facility Information:
Facility name:
Corupany/Owner Organization
Facility address:
(ol) Certificate of Coverage or No Exposure
N I C G.
Michelin Aircraft Tire Company
Michelin N America Inc.
40589 S Stanly School Rd
Address
Norwood NC 28128
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
htt �s:/Ide .nc. rov/abo�rtldivisionslener� -mineral-land-1•esourceslener7 ,-mineral-[and- crn�its!€I �dcs-ir�dtlstrial-
progi,ani and run the Perrnit Contact Stunmary Report,
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Preston
First
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: Shannon
First
Page I of 2
Gray
MI Last
Bernhardt
MI Last
5 W U-©WNERAFI' IL4Nov2019

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Na>ne/Ownership Change)
Plant Manager
Title
40589 S. Stanly School Rd
Mailing Address
Norwood NC 28128
City state zip
( 704 ) 474-7757 [e-mail]
Telephone E-mail Address
( )
Fax Number
5) Reason for this change:
A result of: 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:
1, Shannon Bernhardt , 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 nay
knowledge, I understand that if all required parts of this form are not completed, this change may not be
processed.
nature 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://deg,tio.gov/abet€t/divisions/eiici,gv-mineral-land-resources/storm�,vatei,
Page 2 of 2
S WU-O WNERAFFILANor,2019