NCGNE0465_Name-Owner Change Form_8/3/2018

Environmental
Quakry
I. Permit Information
I. Please enter the permit number for which the change is requested.
NPDES Stormwater Individual Permit #:
NC
SX
XX
XX
X
-OR-
General Permit Certificate of Coverage (COC) #:
NCGNE0465
Use this link to check the permit contact information that is currently in our database.

II. Permit Status
11. Permit status prior to requested change.
a. Permit issued to: Reliance Electric Ind. Co
Company Barre
b. Person legally responsible for permit:
First name:* Middle name: Last name:*
Mark Earley
Title: Plant Manager
Permit holder's mailing address:*
Phone #:*
82865
20074
c. Facility name:*
d. Facility address:*
Fax #:
Street Address
510 Rockwell Drive
Address Line 2
aty
State / Province / Fbgion
Marion
NC
Fbstal / Zip Code
Country
28752
USA
Baldor Dodge Reliance
Street Address
510 Rockwell Drive
Address Line 2
aty
State / Province / Fbgion
Marion
NC
Fbstal / Zip Code
Country
28752
USA
e. Facility contact person (prior to change, optional):
First name: Middle name: Last name:
Corbin Overstre
et
Phone #: [phone]

III. Requested Change Information
111. Please provide the following for the requested change (revised permit).
a. Request for changes is a result r Change in ownership of facility
of: * r Name Change of the facility or owner
b. Permit to be issued to: ABB Motors and Mechanical Inc.
Corrpany Wre
c. Person to be legally responsible for permit:
First name:* Middle name: Last name:*
Mark Earley
Title: Plant Manager
Permit holder's mailing address:*
Street Address
510 Rockwell Drive
Address Line 2
City
Marion
Rxstal / Zip Code
28752
Phone #:* Email address:*
82865 mark.earl
20074 ey@us.a
bb.com
d. Faciltiy name:* ABB Motors and Mechanical Inc.
Is the FACILITY contact different than the person legally responsible
above?*
r Yes
f No
f. Facility contact person:
First name:*
Corbin
Phone #:*
Middle name
8286553963
Last name:*
Overstre
et
Email address:* [e-mail]
State / Frovince / Plegion
North Carolina
Country
USA

IV. Permit Contact Information
Is the PERMIT contact different than the person legally responsible
above?
r Yes
r No
IV. Permit contact information
(if different form the person legally responsible for the permt)
.................................................................................................................................................................................
First Name:* Middle Last Name:*
Corbin Name: Overstre
et
Title: Plant Engineer
Mailing Address:* Street Address
510 Rockwell Drive
Address Line 2
City
Marion
Fbstal / Zip Code
28752
Phone #:* 8286553963
Email Address:* [e-mail]
State / Rovince / Fbgion
NC
Country
USA

V. Permit Facility Activities
V. Will the permitted facility continue to conduct the SAME industrial activities conducted prior to this
ownership or name change:*
r Yes
r No

VI. Signature
In the case of an ownership change request, certifications must be signed by both the permit holder
prior to the change and the new applicant. For a name change request, the signed Permittee's
Certification is sufficient.
This completed application is required for both name change and/or ownership change requests.
North Carolina General Statute 143 - 215.6 b (i) provides that:
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; or who knowingly makes a
false statement of a material fact in a rulemaking proceeding or contested case under this Article; or who falsifies, tampers with, or
knowingly renders inaccurate any recording or monitoring device or method required to be operated or maintained under this Article
or rules of the [Environmental Management] Commission implementing this Article shall be guilty of a Class 2 misdemeanor which
may include a fine not to exceed ten thousand dollars ($10,000).
Permittee Certification: I attest that this application for a name and/or ownership change has been reviewed and is
accurate and complete to the best of my knowledge. I understand that if all required parts of this application are not
completed, or if all required supporting information is not included, this application will be considered incomplete.
Permittee Signature
FLrrrit-holder prior to the ownership change, or permt-holder authorizing the narre change
Will another person need to complete or sign this form before it can be submitted? No problem! Simply CLICK
the "Save as Draft" button below and send the URL link to the other party to access the form. Questions? Call Laura
Alexander at [phone] or e-mail her at [e-mail].

Initial Review
Project ID:* NCGNE0465