NCG030452_Owner Affiliation Change_20220210

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
FNV1 R7 NMFN r At G"A l.I t; (Individual Legally Responsible for Permit)
Use this form if there has been:
FOR AGENCY USE ONLY
Date Received
Year
Month
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 (or) Certificate of Coverage or No Exposure
N I C I S I I I I I I N I C I G D 3 Q 4 5 2
2) Facility Information:
Facility name: Carrier Corporation
Company/Owner Organization: Carrier Corporation
Facility address: 9701 Old Statesville Rd
Address
Charlotte NC 28269
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-pen'nits/npdes-industrial-
rp ogram and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Nimit Bajaj
First M1 1_ast
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: Bruce Jacobson
First MI Lao
Page 1 of 2
5 WU-o WN E RAFFIL4Nov2019

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
5) Reason for this change:
A result of:
tf other please explain:
Plant Manager
Title
9701 Old Statesville Rd
Mailing Address
Charlotte NC 28269
City State Zip
(770 ) 519-5547 [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, Bruce Jacobson , 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
knowle4ge. I understand that if all required parts of this form are not completed, this change may not be
02/09/2022
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:l/deg.nc.gov/about/divisions/energy-mineral-land-resources/stormwater
Page 2 of 2
S W U-O WNE RAFF1 L-4Nov2o l 9