NCG030466_Owner Affiliation Change Request_20220113

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 1/13/2022 11:22:03 AM (Owner Affiliation Change Submission)
Approve by Georgoulias, Bethany A 1/27/2022 8:51:17 AM (Review Assigned to Admin)
* Form was not signed by the right person, but the submitter provided a revised one on 1/26/2022.
Updates have been made in BIMS.
• Georgoulias, Bethany A assigned the task to Georgoulias, Bethany A 1/18/2022 9:29 AM
• The task was assigned to DEMLR SW Admin 1/13/2022 11:22 AM

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Default Page
NPDES Permit
Number*
Submittor's Name*
Phone Number*
Email Address*
Enter your NPDES stormwater permit number or Certificate of Coverage (COC) number.
NCG030466
NCSXXXXXX or NCGXXXXXX
Please enter your FIRST and LAST name
Todd Slack
Please enter your phone number
8287674068
Any format is fine.
Please enter a valid e-mail address
[e-mail]
A confirmation of submission will be e-mailed to this address.
Need a copy of the Permit Owner Affiliation Designation Form? You must upload a signed copy of that form below.
Questions? Call Bethany Georgoulias at [phone] or e-mail her at [e-mail].
Completed Form Please upload the signed "Permit Owner Affiliation Designation Form"
Upload* 2021.01.13_PermitOwner Affiliation Designation.pdf 65.77KB
pdf only

Initial Review
Project ID * Reviewer may revise permit number below if incorrect.
NCG030466

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
ENVIRONMENTAL tENTAL QUALITY (Individual Legally Responsible for Permit)
Use this form if there has been:
FOR AGENCY USE ONLY
Daie Received
Year
Montil
Bay
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
• - ' C 5'`
2) Facility Information:
Facility name:
Company/Owner Organization
Facility address:
(or) Certificate of Coverage or No Exposure
N c 0 13 10 14 16 16
Eaton, Asheville
Eaton Corporation
221 Heywood Road
Address
Asheville NC 28704
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
https ://deg . ne, goy/ab out/divisions/energy-m ineral-land-resources/e nergy-m i neral-land-permits/npdes- industrial-
ro ram and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual:
Dave A Mannebach
First MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person Iegally responsible for this permit:
John A Russler
First MI Last
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S WU-O WNERAFF IL4Nov20 [ 9

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
Plant Manager
Title
221 Heywood Road
Mailing Address
Asheville NC 29704
City State Zip
(828 ) 687-3001 [e-mail]
Telephone E-mail Address
( )
Fax Number
5) Reason for this change:
A result of: [✓ 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, John Russler , 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
processe .
r
1 /12/2022
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 [phone] or visit the website
at: http://deg.ne.gov/about/divisions/energy-mineral-land-resources/stormwater
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