NCG100080_Owner Affiliation Change_20251215

y NC Department of Environmedal Quality
h
Division of Energy, Mineral and Land Resources
r„wrw„ rwt Q..#Iry
Stormwater eReporting Registration Form
Directions are in red.
Completion of the Stormwater Electronic Reporting (eReporting) Registration Form is a
required step for the Owner and, if applicable, other User Account(s) to obtain the privilege of
submitting electronic reports to DEQ and in lieu of submitting paper reports.
= In addition, this form allows for Owners to designate Facility Administrator(s) and Submitter(s)
who can act on their behalf. Owner and User(s) must agree to the Electronic Signature
Agreement (ESA) Conditions contained in this form.
A. Owner Information
The Owner is the legal entity to which whom a permit has been issued. The Owner may be an
individual or organization. Every Owner is required to have a Responsible Official who meets
the legal signature authority requirements in 40 CFR 122.22.
For a corporation, this individual shall a president, secretary, treasurer, or vice-president in charge of
a principal business function, or another individual who performs similar functions for the corporation,
or the manager of one or more manufacturing, production, or operating facilities who is authorized to
make management decisions about the facility operation.
For a partnership or sole proprietorship, this individual shall be a general partner or the proprietor,
respectively, or
For a municipality, State, Federal, or other public agency, this individual shall be either a principal
executive officer or ranking elected official.
Owner dame: Charles Malaniak Title: Dir. of Environmental
Responsible Official Name: Phone: [phone]
Does the Responsible Official ❑ Yes No If Yes,
I already have an eDMR account? User i@D:
_ .... _..—._...__ ...._-- — --....
i Email Address [e-mail]
�.—...
Mailing Address: 5846 Croslhgs Blvd.
city: Antioch State: �TN�Ziv-�37013
Stormwater Electronic Reporting Registration Form
Page 1

B. Pennit Information
Include all stormwater permit currently held by the Owner (both Individual and General
permits). Designate any applicable users for each permit. Attach additional pages if you need
more space.
Pemit rNo.
Facility Name
Facility Address
Name of the User
ff a licable
NCG100080
1140A-Salisbury
1212 Webb Ed. Salisbury, NC 28146
Kyle Brown
NCG 100248
1143-LaGrange
7135 U.S. Hwy 70E LaGrange, NC 28551
Chancy Thomas
NCG100034
1142 Durham
1301 S. Miami Blvd., Durham, NC
Joe Holden
NCG1000095
1168-Raleigh
2928 US 70 Hwy East, Garner, NC 27529
Madleen Steward
NCG100252
1226-Greensboro
Gamer, NC 27529
Diego Mercado
NCGI000064
1227-East NC
4&% US Hwy 13 south Greenville, NC 27834
Julian Harries
NCGl00226
1228-Charlotte
3WO Chesawke Dr., Charolft, NC 28216
Jeff Doebler
Stormwater Electronic Reporting Registration Form
Page 2

C. User Account Information
Include the following information for all User(s) listed in Part B. Attach additional pages if you
need more space.
Click on one or more of the two access roles available: Facility Administrator and/or
Submitter.
If the user enters data and submits report on behalf of the facility, then the Submitter
role should be requested. This role is automatically approved to enter and certify the
data. This person must have signatory authority for the permit.
• If the user is the person responsible for managing user information for the facility/permit,
then the Facility Administrator role should be requested. The Facility Administrator
user can be assigned by the Responsible Official or can be assigned at the time of
registration by the Stormwater eDMR Administrator. Note: If this person is responsible
for submitting eDMR reports, then they must have signatory authority for the permit.
User Account Information Permit Number(s)
NCG100080
Request Access Role:
ZSubmitter
ZFacility Administrator
Name:
Sonya Erickson
Title:
S.E. Region Envtl. Mgr.
Do you already have an eDMR
account?
[]Yes QNo If
UserlD
Yes,
Phone:
5 5-720'4453
Organization:
LKQ Copr.
Email Address.
[e-mail]
Mailing Address:
5846 Crossings Blvd.
City:
Antioch
I State:
JTN
I Zip:
137013
User Account Information Permit Number(s)
NCG100248
Request Access Role:
✓ Submitter
Z
Facility Administrator
Name:
Sonya Erickson
Title:
S.E. Region Envtl. Mgr.
Do you already have an eDMR
account?
If
JEYes ✓� No User
Yes,
ID
Phone:
Organization:
LKQ Corp.
Email Address:
sxehckson@'I'kgcorp.corn
Mailing Address:
5846 Crossings Blvd.
City:
Antioch
State:
TN I
Zip: 137013
User Account Information Permit Number(s)
Request Access Role: ❑Submitter ]Facility Adm6nistrator
_. . _ ........... _ ......_. ......_ ----- _..... ....._.. ...
Name; Title:
Do you already have an eDMR
account?
j_ Yes [E]No
D
FUter
Phone:
Organization:
Email Address:
Mailing Address: _
City
_..........
State: Zip:
Stormwater Electronic Reporting Registration Form
Page 3

D. Electronic Signature Agreement Conditions
To receive and accept the required electronic signature credential, consisting of a User ID and
password, issued by the North Carolina Department of Environmental Quality (NCDEQ) in order
to sign electronic documents submitted to NCDEQ's Electronic Document Systems and to
receive electronic documents from NCDEQ's systems;
The Responsible Official and other User Account(s) (if applicable) named in this form do
herby:
1. Understand that this Electronic Signature Agreement requires me to submit electronic
documents to NCDEQ's approved eDMR system under the authorized program in lieu of
paper submissions.
2. Understand that this Electronic Signature Agreement requires me to accept electronic
transmissions, in lieu of paper transmissions of all permits, permit modifications,
authorizations to construct, and any other correspondence related to reviewing and
processing permits from NCDEQ. This authorization will not become effective until NCDEQ
establishes a system for processing electronic documents; I am notified in writing from
NCDEQ that use of the electronic systems has officially been initiated; and North Carolina
rules and statutes are changed to allow the implementation of electronic submittal and
acceptance of documents.
3. Understand that this Electronic Signature Agreement requires me to submit electronic all
necessary information for processing of NPDES application including information for renewal
of existing permits, modification to existing permits, and applications for new discharge
permits. The submittals may include all necessary applications and supporting documentation
to NCDEQ's approved system for electronic submittals in lieu of paper submissions. This
authorization will not become effective until NCDEQ establishes a system for processing
electronic documents; I am notified in writing from NCDEQ that use of the electronic systems
has officially been initiated; and North Carolina rules and statutes are changed to allow the
implementation of electronic submittal and acceptance of documents.
4. Understand that this Electronic Signature Agreement requires me to accept electronic
submissions, in lieu of paper submissions, of all Notices of Deficiency, Notices of Violation,
Civil Penalty Assessments, and any other correspondence related to compliance with federal
and state water quality laws and regulations that might be sent by NCDEQ. This authorization
will not become effective until NCDEQ establishes a system for processing electronic
documents; I am notified in writing from NCDEQ that use of the electronic systems has
officially been initiated; and North Carolina rules and statutes are changed to allow the
implementation of electronic submittal and acceptance of documents.
5. Agree to protect both the electronic signature credential, consisting of my User ID and
password, and security questions and answers, from compromise and from use by anyone
except me. Specifically, I agree to maintain the secrecy of my electronic signature credential
and security questions and answers; I will not divulge or delegate my credential or security
questions and answers to any other individual; I will not store my credential or security
questions and answers in an unprotected location; and I will not allow my electronic signature
credential or security questions and answers to be written into computer scripts to achieve
automated log -in.
6. Understand and agree that I will be held as legally bound, obligated, and responsible for the
use of my electronic signature as I would be using my hand-written signature.
7. Understand that I will be informed through my registered email address whenever my User ID
or password has been modified.
Stormwater Electronic Reporting Registration Form
Page 4

B. Understand that eDMR reports the last date my User ID and password were used immediately
after successfully logging into eDMR.
9. Agree to contact the NCDEQ SW-eDMR Administrator via email at SW eDMRL7a deg.nc.gov as
soon as possible, but no later than 24 hours, after suspecting or determining that my User ID
and/or password have become lost, stolen or otherwise compromised.
10. Agree that I will review the contents of all electronic submissions prior to submission.
11. Understand that I will automatically receive an email receipt at my registered email address
from the NCDEQ's SW-eDMR system for any submission that contains a valid electronic
signature, identifying the document received, the signatory, and the date and time of receipt.
12. Agree to contact the NCDEQ SW-eDMR Administrator via email at SW-eDMR _deq.nc.gov if I
do not receive an email receipt as specified above within five (5) business days for any
electronically signed submission using my credentials.
13. Agree that if I received an email notification for an activity that I do not believe that I
performed, I will notify the NCDDEQ SW-eDMR Administrator via email at SW-
eDMR(a)deg.nc.gov as soon as possible, but no later than 24 hours, after receipt.
14. Agree to report, within 24 hours of discovery, any evidence of discrepancy between any
electronic document I have signed and submitted and what the NCDEQ eDMR has received
from me by contacting the NCDEQ SW-eDMR Administrator via email at
SW-eDMR@deg. nc.gov.
15. Understand that the NCDEQ eDMR's system will automatically reject any electronic document
submitted without a valid electronic signature if such signature is required.
16. Agree to contact the NCDEQ SW-eDMR Administrator via email at SW-eDMR(cildeg.nc.gov
within ten working days if my duties change and I no'i'onger need to interact with eDMR on
behalf of my organization.
17. Agree to notify the NCDEQ SW-eDMR Administrator via email at SW-eDMR(aD-deq.nc.gov if I
cease to represent the regulated entity specified above as signatory of that organization's
electronic submissions as soon as this change in relationship occurs.
18. Understand that the NCDEQ may contact the Organization's Responsible Official, who signs
below to authorize me as a signatory for the Owner/Organization, in order to verify my identity.
19. Agree to retain a copy of this signed agreement as long as I continue to represent the
regulated entity specified above as signatory of the Organization's electronic submissions.
20. Certify that I have the authority to enter into this Agreement on behalf of the Organization
identified above, and I am a signatory authorized to represent that Organization, and I am able
to sign and submit reports and other information on behalf of that Organization in the capacity
required by statute and/or regu'i'ation.
Stormwater Electronic Reporting Registration Form
Page 5

E. Responsible Official Signature
=::� This form must be completed with an original wet signature (not digital) [40 CFR 122.22]
The Responsible Official, as identified in accordance with 40 CFR 122.22, is the appropriate
individual with the authority to sign and submit reports for the organization.
l
(printed name), have the authority to enter
into
this Agreement for I, o 0 V, (Owner/Organization
Name).
1 request the NCDEQ grant me and, if included in Part B of this form, the named User(s), an
electronic signature credential to submit and accept documents electronically on behalf of my
organization.
I acknowledge that I, and if included in Part B of this form, the named User(s), work at/for my
organization and have authority to submit and accept electronic documents and act as a
signatory for purposes of the NCDEQ's electronic document systems. ,
By submitting this application, I, 0 (% IV S /_ (printed name),
have read, understand, and accept the terms and conditions of this Electronic Signature
Agreement. I certify under penalty of law that I have personally examined and am familiar
with the information submitted in this application and all attachments and that, based on my
inquiry of those persons immediately responsible for obtaining the information contained in
the application, I believe that the information is true, accurate and complete. I am aware that
there are significant penalties for submitting false information, including the possibility of fine
and imprisonment.
esponsible fficial Si nat Title 0 tM 1 ii 4 o b f Dat
eDMR User ID
Stormwater Electronic Reporting Registration Form
Page 6

F. User Signature
Provide a separate page for every User listed in Part B.
= This form must be completed with an original wet signature (not digital) [40 CFR
122.22]
Users other than the Responsible Official who can submit this agreement to request to sign
reports electronically and other information and to accept electronic documents.
1, S'O h L V- C IDS d �I (printed name), am authorized by the
Responsible Official named in this document, who has the authority under the applicable
standards, to enter into this agreement for L Co c D
(Owner/Organization Name).
By submitting this application, I, S h Ev-, c. 6C I'll (printed name),
have read, understand, and accept the terms and conditions of thBs Electronic Signature
Agreement. I certify under penalty of law that I have personally examined and am familiar with
the information submitted in this application and all attachments and that, based on my inquiry
of those persons immediately responsible for obtaining.the information contained in the
application, I believe that the information is true, accurate and complete. I am aware that there
are significant penalties for submitting false information, including the possibility of fine and
imprisonment.
"YE- IlZ ),5 /25
User ignature Title r Date
eDMR User ID
Submit the completed Stormwater Electronlc Reporting Registration Form in hard copy
with original signature to:
DEMLR Stormwater Program eDMR
Attn: Stormwater eDMR Administrator
1'612 Mail Service Center
Raleigh, NC 27699-1612
Stormwater Electronic Reporting Registration Form
Page 7

)) Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
PERMIT OWNER AFFILIATION DESIGNATION FORM
(Individual Legally Responsible for Permit)
Use this form if there has been:
PC.)It A( LN('Y CSC. 6NLY
Uarc Rcc6cd_v
Year
`lunth _
ba
O,C..�.HAN(3,E in facility ownership or, fadlity narne, but the individual
vvho as legally responsible for the pernift has 6hart ed.
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.
NVhat 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 I I I I I�
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
(07) Certificate of Coverage or No Exposure
I N IC I G 11 10 10 12 14T81
LKQ East Carolina
LKQ Southeast Inc
7135 US HWY 70 W
Address
La Grange NC 28551
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
�.tf,. 11d cLj nc1.,«vr,,v,11 Navigate to the "NPDES Industrial Program" section and tim the Stormwater Permit
Contact Summary Report for your permit number.
3) t' 2 OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Marcus Payton
Forst MI Lasm
4) NH�;;W OWN FIt AFFILIATION (legally responsible for the permit):
Person legally responsible For this permit:
Charles Mlalaniak
First MI last
Page I ot'2
Last revised 20 Feb 2022
L

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
Director of Environmental Compliance
Title
73 Willow Avenue
Mauling Address
Rockaway NJ 07866
City State lip
(973 ) 580-3075 cemalania'[e-mail]
Telephone E-mail Address
Fax Number
5) Reason for this change:
A result of: l Employee or management change
Q Inappropriate or incorrect designation before
❑ Other
l f other please explain:
................................................................................................................
The certification below must be completed and signed by the permit holder.
V ,ot lr 40 CFR 122.22(c)requires an original signatUre (notdigital)
PERM17TEE CERTIFICATION:
1. Charles Malaniak , attest that this application for this change in Owner Affiliation
(person legally responsible for the pen -nit) 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.
I1/26/2025
Signature Date
PLEASE SEND THE. ORIGINAL SIGNED COPY OF THE COMPLETED
OWNER AFFILIATION CHANGE FORM TO:
Dh,MLR - Stonnwater Program
Dcpt. of* Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 2769''9-1612
1 or more inf"ormation or staffcontacts, please call [phone] or visit the website
at, hhp'/do'l:tw )'arv/^ w
Ver N(: 6crrcral Statute 143-21 .611 (i), tiny person who knowingly makes tiny litlsc statement, representation, or
certification in any application, record, report, plats, or other document filed or required to be maintained under this
Article or a rule: iinplemenUntr this Article_ . shall he gijilty of"a Class 2 rnisdGntcanor which may include a line not to
Exceed felt thousand dollars ($10,000),
[,age 2 ol'2
laasa revised 21) 1 reb 2022

E Q "�
Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
PERMIT OWNER AFFILIATION DESIGNATION FORM
(individual Legally Responsible for Permit)
Use this form if there has been:
rC)R
AGENCY USG iJNI_Y
�
I)AII. it CCCIYCIr
Year Day
O C 44ANG E its f cHity ownership or, facility naime, bLJt the individual
o I've u , ietiaHy responsible for the Eerrntt has c t'iw)ged,,
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 or No Exposure
I N_[C I I I III N I C I GC 11 10 10 10 18
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
LKQ Salisbury
LKQ Southeast 0nc.
1212 Webb Road
Address
Salisbury NC 28146
-- City State "Lip
I f, find the current legally responsible person assuciated with your permit, go to this website:
�F� d opw, , Navigate to the "NPDES Indusirial Program" section and run the Stormwater Permit
(:untact Su►nrnary Report for your permit number.
) t1U OWNER AFFILIATION that should be removed:
Previous lcgally rer�ponsihle h►(lividual: Marcus
Fitsr MI
4) Ni;W C1WNk;R AI'°IrIL1A'l7ON (legally respor►sllalc for the perrttil):
Person legally responsible for this pernril: Charles
........... .........
Page I of 2
Fbs1 MI
Payton
Last
Malaniak
Last
kw revised 20 ►eb 2022

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
5) Reason for this change:
A result of:
if rather please explain:
Director of Environmental Compliance
Ti0c
73 Willow Avenue
Mailing Address
Rockaway NJ 07866
Ciey State Zip
(973 ) 580-3075 [e-mail]
Telephone Email 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.
iy r 0 CRc requires an original signature (net digital)
PERMITTEE CERTIFICATION:
1. Charles Wialaniak , 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, 1 understand that if all required parts of this form are not completed, this change may not
be processed.
11 /26/2025
Signature Date
PLEASE SEND THE. ORIGINAL SIGNED COPY OF THE COMPLETED
OWNER AFFILIATION CHANCE FORNI TO:
DFMI.R - Stormwater Program
Dept. ol'Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
I of rrtore inf"orrrmalion or staffcontucts, please cull [phone] or visit the website
al: //d1'r) aw P;oYhl W
Pcr W.' Gencral Statute 143-215,611 (i), any Person who knowingly makes tiny Iialse statement, representation, or
certification in any applicalion, record, report, plan, or other document filed or required to be maintained under this
Article or a rule implementing this Article— . shall be guilty ol'a Class 2 misdemeanor which may include a line not to
exceed ten thousand dullars ($10,000),
Page 2 of 2
Lax reviwd .10 Feb 2022