NCS000251_Owner Affiliation_20210607

Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
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:
FOR AGENCY USE ONLY
Date Received
Year
Month
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 (0r) Certificate of Coverage or No Exposure
N C S 0 0 0 2 I N I C I G
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
Conway Resins Plant
Georgia-Pacific Chemicals LLC
200 Amoac Road
Address
Conway NC 27820
City State zip
To find the current legally responsible person associated with your permit, go to this website:
https://deg .nc.gov/about/divisions/energy-mineral-land-resources/energy-mineral-land-permits/npdes-industrial-
rp ogram and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual:
Ronald E
First MI
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
Robert E
First MI
Page 1 of 2
Walls
Last
Dalton
Last
S WU-O WNERAFFIL4Nov2019

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
5) Reason for this change:
A result of:
If other please explain
Plant Manager
Title
P.O. Box 368
Mailing Address
Conway NC 27820
City State Zip
( 404 ) 343-7545 [e-mail]
Telephone E-mail Address
252 ) 585-1754
Fax Number
❑ Employee or management change
❑ Inappropriate or incorrect designation before
❑ Other
Would like to request that Ronald E. Walls stays as co-owerner if possible
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
I, Robert E Dalton , 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.
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://deg.nc.gov/about/divisions/energy-mineral-land-resources/stonnwater
Page 2 of 2
S WU-O WNERAFFIL-4Nov2019

Georgia-Pacific Chemicals LLC
Conway Resins Plant
P.O. Box 368
Conway, NC 27820
Phone [phone]
Fax [phone]
June 7, 2021
Certified Mail — 7019 0160 0001 1456 1655
NCDEQ
Division of Energy, Mineral and Land Resources
1612 Mail Service Center
Raleigh, NC 27699-1612
RE: Stormwater eReporting Registration Form
Dear Ms. McCoy,
Please find the enclosed wetted hardcopy of the Stormwater eReporting Registration Form and the Pen -nit
Owner Affiliation Designation Form for Georgia-Pacific's Conway Resin Plant as requested. This mailed copy
was preceded by an email copy to your attention on June 07, 2021.
We believe that the attached form will meet with your approval. Should you have any questions, please feel free
to contact Tim Riddick at [phone].
Sinc ,
Robert E. Dalton
Plant Manager
w/attachments:
cc: Tim Riddick, Georgia-Pacific Chemicals LLC