HomeMy WebLinkAboutNCG030637 - Baldor Electric #3Division of Energy, Mineral and Land Resources FORAUNCY USE ONLY
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Land Quality Section / Stormwater Permitting Program Year Month Day
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E—RONMENT AND N - AL OWNER AFFILIATION DESIGNATION (FORM
(individual Legally Responsible for Permit)
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If a Flameha;,?g a andlor Ownership pnershi Trak r at the facility ease prompted t1fis chango, do
N T use � form. sou must fiif out the Name -Ownership Change Form and provide at;
I) Enter the permit number for which this change in Legally Responsible Individual ("Owner
Affiliation") applies:
Individual Permit
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
(01) Certificate of Coverage
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To find the current legally responsible person associated with your permit, go to this website:
iiitE.Zjportal.ricdennorg/-,Yeb/lr.%sw-loerrnit-cot7tacts and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed.:
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4) NEW OWNS, R AFFILIATION (Legally responsible for the permit):
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Person legally responsible for this pernvt: ��
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Telephone E—mail Address
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SM-OWNERAFFI L-22May2014
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NPDESStormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Narne/Ownership Change)
5) Reason for this change:
A result of: R Employee or management change
❑ Inappropriate or incorrect designation before
❑ Other
If other please explain:
What does "legally responsible person" mean?
That person is either:
• the responsible corporate officer (for a corporation);
• the principle executive officer or ranking elected official (for a municipality,
State, Federal, or ether public: agency%);
• the general partner or proprietor (for a partnership or sole proprietorship);
• or the duly authorized representative of that person above.
The certification below must be completed and signed by the permit
holder.
PERMITTEE CERTIFICATION:
I,10J � G �) ► NODAR, 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.
Signature I Date
PLEASE SEND THE COMPLETED FORM TO:
Division of Energy, Mineral and Land Resources
Stormwater Permitting Program
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
Por more information or staff contacts, please visit our website:
http:/,�l�or-ial.raccienr. o►,�`��-cb;'l►Ist�►m4vater
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S W U -O W N E R AF F I L-22 M ay2014