NCG030656_Owner Affiliation Change_20211210

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 OUALfTY (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
N I C I S
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
(or) Certificate of Coverage or No Exposure
N I C I G 10 13 10 16 15 16
KSM Castings
KSM Castings USA, Inc.
120 Blue Brook Drive
Address
Shelby NC 28150
City State zip
To find the current legally responsible person associated with your permit, go to this website:
htl I)s:Hdet l.nc. Gov/about/divisions/energy-mineral-land-resources/energ.4 -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: Benjamin Mendez
First MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: Mike Lewis
Page 1 of 2
First MI Last
S WU-O WNERAFF1L4Nov2019

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
Vice President / General Manager
Title
120 Blue Brook Drive
Mailing Address
Shelbv NC 28150
City State Zip
( 859 ) 621-5726 [e-mail]
Telephone E-mail Address
(704 ) 313-0742
Fax Number
5) Reason for this change:
El Employee or management change
A result of: ❑ 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, M I cU A Ei_ t z W " S , 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 Im- all required parts of this form are not completed, this change may not be
processed.
P1, � i 2-/ 10 / .2c, Z 1
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.ne.gov/about/divisions/ener,,y-mineral-land-resources/stormwater
Page 2 of 2
S WU-O WNERAFFIL-4Nov2019

Georgoulias, Bethany
From: Breedlove Crystal <[e-mail]>
Sent: Friday, December 10, 2021 3:03 PM
To: Georgoulias, Bethany
Subject: RE: [External] KSM Castings, Shelby, NC
Attachments: NPDES-Owner-Affiliation-Change-KSM Castings Shelby, NC.PDF
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
Good afternoon Bethany,
I have attached the updated Owner Affiliation record. Please let me know if you need anything else.
Thank you,
CrystaCBreedCove
EHS Engineer
Cell: 704-740-5455
Shelby, NC
Castings
Mit freundlichen Gruf3en / Kind regards
Crystal Breedlove
Environment Mgmt
KSM Castings USA Inc.
120 Blue Brook Drive
28150 Shelby NC
Email: [e-mail]
Web: http://www.ksmcastings.com
1

KSM Castings Group GmbH - Cheruskerring 38 - 31137 Hildesheim - Telefon: [phone] - E-Mail: [e-mail] -
Internet: http://www.ksmcastings.com
Vorsitzender des Aufsichtsrates: Yongsheng Wang
Geschaftsf0hrung: Dr. Zhihua Zhu (Vorsitzender), Patrice Gay
Registergericht Hildesheim, HR B 202841, Sitz der Gesellschaft Hildesheim
Diese Email ist vertraulich and kann privilegierten Inhalts sein. Sie soli nur von dem bezeichneten Empfanger gelesen, kopiert and genutzt
werden. Sollten Sie nicht der bezeichnete Empfanger dieser Email sein, kontaktieren Sie bitte den Absender dieser Email Burch eine Antwort.
Danach I6schen Sie bitte these Email, kopieren Sie these nicht and teilen Sie ihren Inhalt nicht anderen Personen mit. Weder die KSM Castings
Group GmbH noch der Absender Obernehmen die Haftung fur Viren; es obliegt Ihrer Verantwortung, die E-Mail and deren Anhange auf Viren
zu prOfen.
This email is confidential and may be privileged. It may be read, copied and used only by the intended recipient. If you have received it in
error, please contact the sender immediately by return email. Please then delete the email and do not copy the message or disclose its
content to anyone. Neither KSM Castings Group GmbH nor the sender will assume liability for any viruses. The addressee of any email is
responsible for checking each incoming email and its attachments
From: Georgoulias, Bethany [mailto:[e-mail]]
Sent: Wednesday, December 8, 2021 2:59 PM
To: Breedlove Crystal
Subject: RE: [External] KSM Castings, Shelby, NC
Crystal,
I need to know exactly which contacts to update for this permit. Please see below and the attached report.
If Benjamin Mendez has changed, there is a form required to change legally responsible official (the Owner -Owner
affiliation). That form is attached if needed.
Permit: NCGO30656 Version: 5.0 StatLls: ctive
Entity
"Affiliation Type
Name
Title
Phone Number
=acility
Contact Person
Augello, Charles
[phone]
Dwner
Owner
Mendez, Benjamin
[phone]
'ermit
Billing
Ksm Castings NC Inc
[phone]
'ermit
Contact Person
Augello, Charles
[phone]
Bethany Georgoulias (she/her)
Environmental Engineer
Stormwater Program, Division of Energy, Mineral, and Land Resources
N.C. Department of Environmental Quality
919 707 3641 office
[e-mail]
512 N. Salisbury Street, Raleigh, NC 27604 (location)
1612 Mail Service Center, Raleigh, NC 27699-1612 (mailing)
Website: http://deq.nc.gov/about/divisions/energy-mineral-land-resources/stormwater
Email correspondence to and from this address is subject to the

North Carolina Public Records Law and may be disclosed to third parties
Based on the current guidance to minimize the spread of COVID-19, the Department of Environmental Quality has
adjusted operations to protect the health and safety of the staff and public. Many employees are working remotely or
are on staggered shifts. To accommodate these staffing changes, all DEQ office locations are limiting public access to
appointments only. Please check with the appropriate staff before visiting our offices, as we may be able to handle your
requests by phone or email. We appreciate your patience as we continue to serve the public during this challenging
time.
From: Breedlove Crystal [mailto:[e-mail]]
Sent: Wednesday, December 8, 2021 1:27 PM
To: Georgoulias, Bethany <[e-mail]>
Subject: [External] KSM Castings, Shelby, NC
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
Hi Bethany,
I would like to introduce myself as the new EHS Engineer at:
KSM Castings USA, Inc.
120 Blue Brook Drive
Shelby, NC 28150
GENERAL PERMIT NO. NCG030000
Certificate of Coverage No. NCG030656
My predecessors are no longer at this facility so please feel free to update the contact information for this facility. If you
have a formal form or site where I should update my information, please let me know and I will get it updated ASAP. My
cell phone number is listed in the email signature below.
Thank you,
Crystal Breedlove
EHS Engineer
Cell: 704-740-5455
Shelby, NC
.A7u
Castings