NCG030229_Owner Affiliation Change_20210727

Division of Energy, Mineral, and Land Resources
r
Land Quality Section / Stormwater Program t I �v. National Pollutant Discharge Elimination System (NPDES)
Energy, Mineral & PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resources
ENVIRONMENTAL GUAL17Y (Individual Legally Responsible for Permit)
Use this form if there has been:
FOR AGENCY USE ONLY
Date Received
Year
Montle
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 (or) Certificate of Coverage or No Exposure
N I C I S I I I I I N I C I G 10 3 0 2 9 9
2) Facility Information:
Facility name: Eaton Corp -Transmission Div
Company/Owner Organization: Eaton Corp -Transmission Div
Facility address: 744 S Battleground Ave
Address
Kings Mountain NC 28086
City state Zip
To find the current legally responsible person associated with your permit, go to this website:
https://deg.nc.goy/about/divi sions/enemy-mineral-land-resources/enemy-mineral-land-perm industrial-
programits/npdes-and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Boukary
First
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
Travis
First
Page I of 2
I Maiga
MI Last
L Cunningham
MI Last
9 WU-OWNFRAFFIL lNov2019

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
744 S Battleground Ave
Mailing Address
Kings Mountain NC 28086
City State Zip
(704 ) 937-4379 [e-mail]
Telephone E-mail Address
(704 ) 937-4494
Fax Number
✓0 Employee or management change
Inappropriate or incorrect designation before
❑ Other
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
1, Travis Cunningham , 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.
�Z72
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: .1=--,---- -
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S W U-O W NERAFFIL-4Nov2019