NCG030229_Owner Affiliation Change_7/30/2019

Division of Energy, Mineral, and Land Resources
Use this form if there has been -
FOR AGENCY USE ONLY
Date Reeeived
Year
I Month
I Day
NO
CHANGEy or 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
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
(or) Certificate of Coverage
N C G 3 10 12 12 191
Eaton Corp -Transmission Div
Eaton Corporation
744 S Battleground Ave
Address
Kings Mountain NC 28086
City state .Zip
To find the current legally responsible person associated with your permit, go to this website:
htt ://de .nc. ov/about/divisions/ener, -mineral-land-resources/ener -mineral-land- ennits/stormwater- ro am
and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Nina
Lockmam
First Na Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: Boukary Maiga
First NU Last
Page 1 of 2
s WU-OWNERAFFnr23D&reh2017

L r ozl�rnrsz�3rmo-nuns
Z3o Z a2ed
zalumum s/saoinosaz-puui-Ieaauluz- aaua/suolsrnrp/inoge/no -ou apll= q :iu
ailsgom agi ilsln xo OZZ6-LOL (6I6) Iiuo oseaid `siouiuoo GIs xo uoi euuoTm axom zod
DI-eQ
ZI9I-669LZ uulloJuD ulxoN `l#'P N
xaivaD aolnxaS ireW ZI9I
,4411etto Muauzuo,zrnug;o •IdaQ
u�uJ�oxd xaiumuuoiS - 2�'II�IgQ
:QL ViU0a (IaIH IdW0a AHZ a[KgS aSVald
6 WZ16Z/LO
•passaooxd
aq iou Xeut anuetio spp `paiaiduzoa Iou axe uuoj slrlio spud pa rmbaa Iiu jl ie pueisxapun i apaimomi
Buz jo isoq aql of aiaidruoo pu-e a}umaau st pue pamaleax uaaq seta (iluuod oill aoj aiglsuodsax XIiuOOi uosxad)
uorlurir -v xaum0 ul a5uurio srrp jq; uoliuoliddu slrli Ieul isaiie e6ien fuminoe `I
KollvOIm,IuaD aalll"Acl
aaploq I!wjad aql Aq pauBis pue pajejdwoo eq Isnw nnolaq uoijeoilpao ayl
xatil0 ❑
o.zojaq uoliuuOtsop ioaxxooui xo oiuudoxdduul El
o2uuria iuouiafeumm xo oaXoiduzg ❑
.tagmn& xe,d
ssazppVffem-a auogd;pj
wo3•uoiea@e6ievvj/ueNnog QL£iTL£6 ( b01 )
d1z
9S09Z ON urelunoW sbuiN
ssaippy fluFlr�
all€ j
eny pUn0J6alIIe9 S 17'L
196euen Iue]d
:uivjdxa asnajd iagjo fj
-To iinsas y
:a uuga stgl Yoj u©sua-d (S
(atuuga digsxqueap/auxuN 4q!;)uj ou jj)
uaaozl NOLLVNJIS20 NOUVIIddV N3NMO PWJ9d J9lennuaa0IS S3OdN