NCG030729_Owner Affiliation Change_20221012

DE Division of Energy, Mineral, and Land Resources
NORTH CAROLINA Land Quality Section / Stormw Program
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National Pollutant Discharge Elimination System (NPDES)
PERMIT OWNER AFFILIATION DESIGNATION FORM
(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.
/f 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:
(or) Certificate of Coverage or No Exposure
MEEMMMMMM
PowerSecure Manufacturing Inc. - PowerFab
PowerSecure Manufacturing, Inc.
1410 Coltrane Mill Rd.
Randleman
City
Address
NC
State
27317
Zip
To find the current legally responsible person associated with your permit, go to this website:
https://deg.ne.gov/sw/ Navigate to the "NPDES Industrial Program" section and run the Stormwater Permit
Contact Summary Report for your permit number.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Scotty
First
4) NEW, OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
Last revised 20 Feb 2022
Jason
First
Page 1 of 2
Moates
MI Last
Mitchell
MI Last

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:
Director of Manufacturing
Title
4068 Stirrup Creek Dr.
Mailing Address
Durham NC 27703
City State Zip
(919 ) 761-0277 [e-mail]
Telephone E-mail Address
( )
Fax Number
❑ Employee or management change
❑ Inappropriate or incorrect designation before
❑ Other
...................................................................................... 0........ 0...................
The certification below must be completed and signed by the permit holder.
Note: 40 CFR 122.22(c) requires an original signature (not digital)
PERMITTEE CERTIFICATION:
I, Jason Mitchell , 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.
r
.I- Al,. -/tr
Signature
Date
PLEASE SEND THE ORIGINAL SIGNED COPY OF THE COMPLETED
OWNER AFFILIATION CHANGE 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/sw
Per NC General Statute 143-215.6B (i),any person who knowingly makes any false statement, representation, or
certification in any application, record, report, plan, or other document filed or required to be maintained under this
Article or a rule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars ($10,000).
Last revised 20 Feb 2022 Page 2 of 2