NCG030500_Owner Affiliation Form_20180706

na Division of Energy, Mineral, and Land Resources FOR AGENCY USE ONLY
". Date Received
Land Quality Section / Stormwater Program Year Month Day
National Pollutant Discharge Elimination System (NPDES)
Energy, Mineral It PERMIT OWNER AFFILIATION DESIGNATION FORM
Lund Resources
t•NVIR014Mt.NTALOUALITY (Individual Legally Responsible for Permit)
Use this form if there has been:
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 till 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 o liL�ri/Ep
agency); JUL Q 6 1013
• the general partner or proprietor (for a partnership or sole proprietorship);
• or, the duly authorized representative of one of the above. OR NR.LANtp QUALI
ST MWATER PP TY
Enter the permit number for which this change in Legally Responsible Individual ("Owner Affilialid4')7/IVG
applies:
1)
Individual Permit (or)
N I C I S
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
Certificate of Coverage
N I C I G 10 13 10 15 10 10
GE Lighting Solutions, LLC
GE Lighting Solutions
3010 Spartanburg Hwy.
Address
East Flat Rock NC 28726
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
http://deq.nc.gov/about%divisions/ener,"-mineral-land-resources/enera-mineral-land-permits/stonnwater-pro ,Tram
and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual:
First MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
Page 1 of 2
S WU-OWNE RAF F IL-2 3 March2017
First Ml Last

NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
5) Reason for this change:
A result of:
If other please explain:
Plant Manager
Title
3010 Spartanburg Hwy.
Mailing Address
East Flat Rock NC 28726
City State Zip
Telephone E-mail Address
(!R28) & t3^ Z 37 7 6kv.:J,r,�r t;,✓��9e- c 41
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, PA VI 2D vl A RZn (14 , 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
ces
l
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.nc.gov/about/divisions/energy-mineral-land-resources/stonnwater
Page 2 of 2
S WU-OWNERAFFIG23Mar2017

June 29, 2018
SW General Permit Coverage Renewal
Storm water Permitting Unit
Attention: Laura Alexander
1617 Mail Service Center
Raleigh, NC. 27699-1617
RE: Certificate of Coverage Number NCG030500
Laura:
General Electric
Lighting Solutions
David R. Martin
Plant Manager
3010 Spartanburg Hwy
East Flat Rock, NC 28726
USA
T 828 693 2625
[e-mail]
"JC o V �1�
6 10%B
0����WA7 QUALITY
R P6RMI SING
Enclosed is the current renewal information with the updated permit owner affiliation
designation form. Per conversation on the phone this is all that is needed at this time in
order to renew our storm water permit. Our facilities annual renewal fee of $100.00 was
paid back on 5/23/18. If you have any questions or comments, please contact my EHS
Engineer Steve Floyd at 828-693-2413 or via email [e-mail].
Sincerel ,
-
David R. Martin
Plant Manager
GE Lighting Solutions