NCGNE0993_Owner Affiliation Change_9/25/2019

NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
EHS Manager
Title
PO Box 247
Mailing Address
Elon NC 27244
City State Zip
(336 ) 449 7261 [e-mail]
Telephone E-mail Address
(336 ) 449 6594
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:
I, Michael Fitzpatrick _, 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.
AC
Signatur 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: htt://de .nc. ov/about/divisions/ener -mineral-land-resources/stonnwater
Page 2 of 2
SWU-0WNERAFFIL-23Mar2017

Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
........ ..............:....
cry rntcl! PERMIT OWNER AFFILIATION DESIGNATION FORM
td° (Individual Legally Responsible for Permit)
�rt�i'�PiCN i.AL C#S�U•YY
Use this form if there has been:
FOR AGENCY USE ONLY
Date Rcccivcd
Year
Month
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 rill 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
N I C I GIN JE 10 19 9 3
Engineered Controls International - Elon
Engineered Controls International LLC
100 Recto Dr
Address
Elon NC 27244
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
htip:Hde!a.nc.p,ov/about/divisions/energy-mineral-land-resources/energy-mineral-land-perniits/stormwater program
and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Jimmy
First
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
Michael B
First
Pagel of 2
McCandles
MI Last
Fitzpatrick
MI Last
SWU-OWNERAFFIL-23March 2017