NCG030612_Owner Affiliation Change_12/13/2019

Energy, Mineral &
Land Resvurces
EtJVIRONM6NfAl QUALITY
Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
PERMIT OWNER AFFILIATION DESIGNATION FORM
(Individual Legally Responsible for Permit)
Use this form if there has been:
FOR AGENCY USE ONLY
Date Received
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 fill out aName-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 offices• or ranking elected official (for a municipality, state, federal or other public
agency);
• the general partner or proprietor (for a partnership or sole pt•oprietorship);
• 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:
(o�^) Certificate of Coverage or No Exposure
N C G 0 3 0 6 1 2
GOULDS PUMPS INC.
GOULDS PUMPS INC.
1115 PLEASANT RIDGE ROAD
Address
GREENSBORO NC 27409
City
State Zip
To find the current legally responsible person associated with your permit, go to this website:
https://deq.nc.�ov/about/divisions/energy-mineral-land-resources/enemy-mineral-land-permits/npdes-industrial-
rop gram and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: AL
First
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for• this permit:
JAMES
First
BADER
MI Last
MI
DURNELL
Last
S WU-OWNERAFFIL�4Nov2019
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NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
5) Reason for this change:
A result of:
If other please explain:
Form (if no Facility Name/Ownership Change)
FACILITY MANAGER
Title
1115 PLEASANT RIDGE ROAD
GREENSBORO
City
336 � 662-0113
Telephone
336 1 662-0116
Fax Number
Mailing Address
NC 27409
State Zip
[e-mail]
E-mail Address
®✓ 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, JAMES DURNELL
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
It .
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://deq.nc.gov/about/divisions/energy-mineral-land-resources/stormwater
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S WU-OWNERAFFIL-4Nov2019