NCG030238_Owner Affiliation Change_20210618

FOR AGENCY USE ON! Y
Data Received
Yeax Month I Day
National Pollutant Discharge Elimination System (NPDES)
PERMIT
Legally « Permit)
Use this form if there has been:
who is legal y respo,,,,'�sibme for the pe raft hms chaoged,
If the name f the facility has changed, or if the own of the facility has changed,
do NOT use fhis form. Instead, you must fill out a Name -Ownership Change Form
and submit the completed form with all required door entation.
What does "legally responsible individual" mean?
The person is either:
® the responsible corporate officer (for a co€lporatio ),
* the principle executive officer- or acing elected official (for a municipality, state, fedtrai o1 other public
.agency);
* the general partner or proprietor (for a partnership or sole proprietarship),�
e 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-
Individo.al Permit
) Facility Information:
Facility name:
Company/Owner Organization
Facility address:
c� } Certificate of Coverage or No Exposer,;
Siemens Energy Inc.
Siemens Energy, Inc.
3050 Westinghouse Road
Address
Rural Hall NC 2704
City State Zip
To find the current legally responsible person associated with your permit, g® to this website:
... 'I?i)) . E. c?,t a �: , rr 1 ,a 1 .-qj,
pro ra x n and run the Permit Contact Summary Report,
3) OLD OWNER AFFILIATION that should be removed -
Previous legally responsible individual: Arnogh Bhonde
First M1 Last
) NEW OWNER AFFILIATION (legally responsible for the permit) -
Person legally responsible for this permit: Cory Phillips
First MI Last
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NPDES Stormwater Permit OWNER AFFILIATION I NATI N
Form (if no Facility Name/Ownership Change)
Facility Manager
Title
3050 Westinghouse Road
TOailing Address
Rural Hall NC 27045
City State Zip
(336 ) 969-1230 cory,[e-mail]
Telephone Email Address
Fax Plumber
5) Reason for this change:
A result of� El Employee or -iynanagemeni chaRg€;
rl InappropriatQ or incorrect designation before
ED Other
�f other please explain -
The i i a ion below must be completedand signedthe permit holder.
RMI'TTEE URTTFC TI 1:
I9 Cory Philips � attest that this application for this change in Owner Af l iation
(person legally responsible for the permit) has been reviewed and is accurate, and complete to the best of taffy
knowledge, I understand that if all required parts of this form are not completed, this change may not be
processed.
I J
::. ,.... Sig -nature i
Date
4
PLEASE SEND THE COMPLETED FORM TO,
DEMLR - Stor_mwater Program
Dept. of Enviro=cntal 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 z Ilc,gc /a' i1 t- i � l 11€
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