NCG030452_Owner Affiliation Change_20191223

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 ENVIRONMENTAL QUALITY(Individual Legally Responsible for Permit)
Use this form if there has been:
FOR AGENCY USE ONLY
Date Received
Year
Month
Da
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? RECEIVED
The person is either: PT'C r? 3 [0'9 M90
• the responsible corporate officer (for a corporation);
• the principle executive officer or ranking elected official (for a municipality, state feaNfo.ppgt8g,pic
agency); SfiGR;M? IVATER PERMi?' y
• 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
N I C I S N C G 0 3 0 4 5 2
2) Facility Information:
Facility name: Carrier Charlotte Operations
Company/Owner Organization: United Technologies
Facility address: 9701 Old Statesville Road
Address
Charlotte N.C. 28269
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
http•//deq nc.gov/about/divisions/energy-mineral-land-resources/energy-mineral-land-permits/stormwater-12rogram
and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: JUAN J GARZA
First MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: GREGORY MITCHUM
First M 1 Last
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SM-OWNERAFFIL-23March2017

NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
Sr. Director Operations Charlotte Plant
Title
9701 Old
Statesville Rd
Mailing Address
Charlotte N.C. 28269
City State Zip
[phone] [e-mail]
Telephone E-mail Address
Fax Number
5) Reason for this change:
A result of: ® Employee or management change
❑ Inappropriate or incorrect designation before
❑ Other
If other please explain: NEW PLANT MANAGER
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
I, c l Eck_ VV (�' `,�ZS _ , 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.
/c Loa
ate
PLEASE SEND THE COMPLETED FORM TO:
Division of Energy, Mineral, and Land Resources
Stormwater Program
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
For more information or staff contacts, please call [phone] or visit the website at:
httR://deg.nc. gov/about/divisions/energy-mineral-land-resources/stormwater
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SW U-OWNERAFFI L-23Mar2017