NCG030027_Permit Owner Affiliation Designation_20200702

Division of Energy,Mineral, and Land Resources FOR AGENCY USE ONLY
Land Quality Section/Stormwater Program Date Received
y,a g Yeaz Month Day
National Pollutant Discharge Elimination System (NPDES)
Energy,Mineral& PERMIT OWNER AFFILIATION DESIGNATION FORM RECEIVED
Land Resources
ENVIRONMENTAL QUALITY (Individual Legally Responsible for Permit) JUL 02 ;41►;i1
Use this form if there has been: %jowly
STORM WATER TTINc
NO CHANGE in facility ownership or facility name, but the individuate
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
N C S N C G 0 3 0 0 2 7
2) Facility Information:
Facility name: Eaton Roxboro
Company/Owner Organization: Eaton Corporation
Facility address: 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://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: Scott K Bailey
First MT Last
4) NEW OWNER AFFILIATION(legally responsible for the permit):
Person legally responsible for this permit: Andrew B Short
First MI Last
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S W U-O W NERAFFIL4Nov2019

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
Plant Manager
Title
2564 Durham Road
Mailing Address
Roxboro NC 27573
City State Zip
(336 )503-6536 [e-mail]
Telephone E-mail Address
( )
Fax Number
5) Reason for this change:
A result of: 0 Employee or management change
❑ 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, 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.
24,,7f— 6/4/2020
Signature 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
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SWU-OWNERAFFIL 4Nov2019