NCG030027_Owner Affiliation Change_20200605

McCoy, Suzanne
From: Bloomer, Edmara D <[e-mail]>
Sent: Friday, June 5, 2020 6:55 AM
To: McCoy, Suzanne
Subject: RE: [External] EHS Manager - Eaton Corporation — Roxboro, NC facility - Facility
contact person
Attachments: 2020-06-05 - NPDES Owner Affiliation Change.pdf
Attached is the completed form. I will send the original in the mail.
Thanks and have a great day.
Edmara Bloomer
EHS Manager, Vehicle Group North America
tel: [phone] mobile: [phone]
edmaradbloomera-eaton.com
From: McCoy, Suzanne <[e-mail]>
Sent: Thursday, June 4, 2020 3:36 PM
To: Bloomer, Edmara D <[e-mail]>
Subject: RE: [External] EHS Manager - Eaton Corporation — Roxboro, NC facility - Facility contact person
Owner Designation/Affiliation Form
Here is a link to a blank form, I responded before I really looked at your attachment.
Email it to me, and send the original in the mail.
Once I receive the new form I'll update the database.
Thank you
Suzanne
Stormwater Program Administrative Specialist
Division of Energy, Mineral and Land Resources
Department of Environmental Quality
512 N. Salisbury Street, Office 640K, Raleigh, NC 27604
1612 Mail Service Center, Raleigh, NC 27699-1612
919-707-3640
Based on the current guidance to minimize the spread of COVID-19, the Department of Environmental Quality has
adjusted operations to protect the health and safety of the staff and public. Many employees are working remotely or
are on staggered shifts. To accommodate these staffing changes, all DECO, office locations are limiting public access to
appointments only. Please check with the appropriate staff before visiting our offices, as we may be able to handle your
requests by phone or email. We appreciate your patience as we continue to serve the public during this challenging
time.

correspondenceEmail . and from re
From: Bloomer, Edmara D [maiIto: [e-mail]]
Sent: Thursday, June 4, 2020 3:24 PM
To: McCoy, Suzanne <[e-mail]>
Subject: RE: [External] EHS Manager - Eaton Corporation — Roxboro, NC facility - Facility contact person
Hi Suzanne,
I need to update the site — Signed NPDES Owner affiliation. I have the form attached in our file, but I am not sure if I
need to complete that or you can update that by email. If I need to submit the form, can you please send that to me?
We need to replace Scott K Bailey to Andrew B Short.
Thank you in advance,
Edmara Bloomer
EHS Manager, Vehicle Group North America
tel: [phone] mobile: [phone]
edmaradbloomera-eaton.com
From: McCoy, Suzanne <[e-mail]>
Sent: Monday, May 18, 2020 1:12 PM
To: Bloomer, Edmara D <[e-mail]>
Subject: RE: [External] EHS Manager - Eaton Corporation — Roxboro, NC facility - Facility contact person
IF •
Suzanne
Stormwater Program Administrative Specialist
Division of Energy, Mineral and Land Resources
Department of Environmental Quality
512 N. Salisbury Street, Office 640K, Raleigh, NC 27604
1612 Mail Service Center, Raleigh, NC 27699-1612
919-707-3640
Based on the current guidance to minimize the spread of COVID-19, the Department of Environmental Quality has
adjusted operations to protect the health and safety of the staff and public. Many employees are working remotely or
are on staggered shifts. To accommodate these staffing changes, all DECO, office locations are limiting public access to
appointments only. Please check with the appropriate staff before visiting our offices, as we may be able to handle your
requests by phone or email. We appreciate your patience as we continue to serve the public during this challenging
i

correspondenceEmail . and from re
From: Bloomer, Edmara D [maiIto: [e-mail]]
Sent: Monday, May 18, 2020 12:32 PM
To: McCoy, Suzanne <[e-mail]>
Subject: RE: [External] EHS Manager - Eaton Corporation — Roxboro, NC facility - Facility contact person
Yes, Please remove Colin W. Betchan
Thank you,
Edmara Bloomer
EHS Manager, Vehicle Group North America
tel: [phone] mobile: [phone]
edmaradbloomera-eaton.com
From: McCoy, Suzanne <[e-mail]>
Sent: Monday, May 18, 2020 10:56 AM
To: Bloomer, Edmara D <[e-mail]>
Subject: RE: [External] EHS Manager - Eaton Corporation — Roxboro, NC facility - Facility contact person
In 24 hours you will be able to run a Permit Contacts Report, found at:
https://deg.nc.gov/about/divisions/energy-mineral-land-resources/npdes-industrial-stormwater
Suzanne
Stormwater Program Administrative Specialist
Division of Energy, Mineral and Land Resources
Department of Environmental Quality
512 N. Salisbury Street, Office 640K, Raleigh, NC 27604
1612 Mail Service Center, Raleigh, NC 27699-1612
919-707-3640
Based on the current guidance to minimize the spread of COVID-19, the Department of Environmental Quality has
adjusted operations to protect the health and safety of the staff and public. Many employees are working remotely or
are on staggered shifts. To accommodate these staffing changes, all DECO, office locations are limiting public access to
appointments only. Please check with the appropriate staff before visiting our offices, as we may be able to handle your
requests by phone or email. We appreciate your patience as we continue to serve the public during this challenging

Email correspondence o and from this address is subject
From: Bloomer, Edmara D[maiIto: [e-mail]]
Sent: Monday, May 18, 2020 10:34 AM
To: McCoy, Suzanne <[e-mail]>
Subject: [External] EHS Manager - Eaton Corporation — Roxboro, NC facility - Facility contact person
Suzanne,
My name is Edmara Bloomer and I am the new EHS Manager - Eaton Corporation — Roxboro, NC facility.
Could you please update the facility contact person and include myself? My contact information are listed below.
Thank you in advance,
Edmara Bloomer
EHS Manager
Vehicle Group North America, Eaton
2564 Durham Rd I Roxboro, NC 27573
tel: [phone] mobile: [phone]
edmaradbloomera-eaton.com
f eaton.coml
Connect with Eaton:
�f � 'flinkedin.coml [113_Ltwitter.coml fyoutube.coml ffacebook.coml

Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
Energy, Mineral & PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resources (Individual Legally Responsible for Permit)
ENVIRONMENTAL s
Use this form if there has been:
FOR AGENCY USE ONLY
Date Rei ecved
Yearl
Month
I 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 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 I C I S
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
(ar) Certificate of Coverage or No Exposure
N I C I G 1 0 3 0 0 2
Eaton Roxboro
Eaton Corporation
2564 Durham Road
Address
Roxboro NC 27573
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
https•//deg nc gov/about/divisions/energy-mineral-land-resources/energy-mineral-land-permits/npdes-industrial-
rp ogram and nm the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Scott K Bailey
First MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: Andrew
B Short
First ML Last
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S W U-O W NERAFFILANov2019

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
5) Reason for this change:
A result of:
If other please explain:
Plant
Title
2564 Durham Road
Mailing Address
Roxboro NC 27573
City State Zip
(336 )503-6536 [e-mail]
Telephone E-mail Address
Fax Number
✓❑ 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 Andrew B. Short 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.
LQtu 24,�
Signature
6/4/2020
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.nc.gov/about/divisions/energy-mineral-land-resources/stormwater
Page 2 of 2
S W U-O W NERAFFIL-0Nov20l9