NCG030006_Owner Affiliation Change_20211231

FOR AGENCY USE ONLY
Date Received
Year
Month
Day
Use this form if there has been:
CHANGENO ownership or w
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 C S
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
(or) Certificate of Coverage or No Exposure
N C G 0 13 1010 0 6
ABB Inc - Edgecombe
ABB Inc
3022 NC HWY 43 N
Address
Pinetops NC 27864
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
Iittps:Hdeg.ne.goi,/abou.t/divisions/ever.,y-mineral-1 and-resources/energy-mineral-land-permits/nudes-indtistri raI-
rp ogram and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Tobias
First
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this pen -nit:
Lynch
MI fast
Andrew Meehan
First MI Last
S WU-OWNERAFFIL4Nov2019
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NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
Local Product Group Manager
Title
3022 NC HWY 43 N
Mailing Address
Pinetops NC 27864
City State Zip
(731 ) 4396860 [e-mail]
Telephone E-mail Address
)
Fax Number
5) Reason for this change:
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:
1, Andrew Meehan , 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 erstand f a] equired 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.ne.gov/about/divisions/energy-minera.!-land-resources/storniwater
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S WU-O WNERAFFIL-4Nov2019