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HomeMy WebLinkAboutNCS000370_Permit Owner Affiliation Designation_20190722Energy. 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 norrodvergil@bfusa.com 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 (919) 707-9220 or visit the website at: http://dey.nc.gov/about/divisions/energy-mineral-land-resources/stonnwater Page 2 of 2 S WU-OWNERAFFIIr2 War2017