NCG030579_Owner Affiliation Designation_20200107

Division of Energy,Mineral, and Land Resources FOR AGENCY USE ONLY
Date Received
t.^a
Land Quality Section /Stormwater Program Year Month Day
National Pollutant Discharge Elimination System (NPDES)
Energy,Mineral& PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resources ENVIRONMENTAL QUALITY (Individual Legally Responsible for Permit)
Use this form if there has been:
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
NCS N C G 0 3 0 5 7 9
2) Facility Information:
Facility name: Schindler Escalator Plant
•
Company/Owner Organization: Schindler Elevator Corp
Facility address: 609 Industrial Drive
Address
Clinton NC 28328-9745
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
https://deq.nc.gov/about/divisions/energy-mineral-land-resources/energy-mineral-land-permits/npdes-industrial-
program and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Richard Pearson
First MI Last
4) NEW OWNER AFFILIATION(legally responsible for the permit):
Person legally responsible for this permit: John Baxter
First MI Last
Page 1 of 2
S WU-O WNERAFFIL4Nov2019

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
Managing Director
Title
609 Industrial Drive
Mailing Address
Clinton NC 28306-9745
City State Zip
(910 )590-5529 [e-mail]
Telephone E-mail Address
(910 )590-5575
Fax Number
5) Reason for this change:
0 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, John Baxter ,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.
Aj ,', y m3 2mm
J � 2
/Sig ature 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(919) 707-9220 or visit the website
at: http://deq.nc.gov/about/divisions/energy-mineral-land-resources/stormwater
Page 2 of 2
S WU-OWNERAFFIL-4Nov2019

NC Division of Energy, Mineral and Land Resources
NPDES Stormwater Permit Contacts Summary
NC DEMLR has the follossin contact information in our Permit Database for sowr permit as of 1/3/2020.
Permit Number: NCG030579
Permit Type: Metal Fabrication Stormwater Discharge COC
Facility Name: Schindler Escalator Plant
Facility Addressl: 609 Industrial Dr
Facility Address2:
City,State&Zip: Clinton,NC 28328-9745
Owner Information Details:
MUST submit a Change of Name/Ownership form to DEMLR to make any changes to this Owner information.
(Click Here for"Change of Name/Ownership"Form)
Owner Name: Schindler Elevator Corp
Owner Type: Non-Government Owner Type Group: Orydniintion
*** Legally Responsible for Permit***
(Responsible corporate officer/principle executive officer or ranking elected official/general partner or proprietor;
or any other person with delegated signatory authority from the legally responsible person.) J_
Owner Affiliation: 1 j 0% AX,4,.,r .r. Title: MAd/� t A/ D1(,GTO 1-
Addressl: 609 Industrial Dr L)
Address2:
City,State&Zip: Clinton,NC 28328-9745 Work Phone: D0€r C A8 q (0 - 59 0- 5 =�1 Vi Fax: [phone]
Email Address: iciaabd f
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*** Permit Annual Fee Billing ***
Billing Month: February
Invoice Number Invoice Date Invoice Due Date Invoice Amount Invoice Status
Owner Contact Person(s)
Contact Name Title Address Phone Fax Email
Facility Contact Person(s)
.Contact
Name Title Address Phone Fax Email
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Permit Contact Person(s)
Contact Name Title Address Phone Fax Email
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Permit Billing Contact
Contact Name Title Address Phone Fax 5575 Email
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