NCS000211_Name-Owner Change Form_20191116

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 11/16/2019 7:48:06 AM (Name Change Submission)
Approve by McCoy, Suzanne 11/25/2019 8:44:31 AM (Notification to Admin)
• The task was assigned to McCoy, Suzanne 11/16/2019 7:48 AM

NORTH CAROLINA
EmlmnmerrW Quality
I. Permit Information
I. Please enter the permit number for which the change is requested.
NPDES Stormwater Individual Permit #:
NCS000211
NC
SX
XX
XX
X
-OR-
General Permit Certificate of Coverage (COC) #:
NC
GX
XX
XX
X
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: International Paper Company
Conpany f brre
b. Person legally responsible for permit:
First name:* Middle name
Adam
Title:
Permit holder's mailing address:*
Phone #:*
252-
633-
7229
c. Facility name:*
d. Facility address:*
Fax #:
Last name:*
Miklos
Mill Manager
Street Address
1785 Weyerhaeuser Road
Address Line 2
oty
State / F rovince / Fbgion
Vanceboro
NC
Fbstal / Zip Code
Country
28586-7606
us
International Paper Company
Street Address
1785 Weyerhaeuser Road
Address Line 2
oty
State / F rovince / Fbgion
Vanceboro
NC
Fbstal / Zip Code
Country
28586-7606
us
e. Facility contact person (prior to change, optional):
First name: Middle name: Last name:
Stephen DiPiero
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:* International Paper Company
Company femme
c. Person to be legally responsible for permit:
First name:* Middle name
Adam
Title:
Permit holder's mailing address:*
Last name:*
Miklos
Street Address
1785 Weyerhaeuser Road
Address Line 2
city
Vanceboro
Postal / Zip Code
28586-7606
Phone #:* Email address:*
252- adam.mik
633- los@ipap
7229 er.com
d. Faciltiy name:* International Paper Company
Is the FACILITY contact different than the person legally responsible
above?*
r Yes
r No
f. Facility contact person:
First name:
Stephen
Phone #:*
Middle name
252-633-7633
Email address:* [e-mail]
Last name:*
DiPiero
State / Province / Region
NC
Country
us

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 formthe person legally responsible for the perrrit)
......... .........
First Name:* Middle Last Name:*
Jacquely Name: Taylor
n
Title: EHS Manager
Mailing Address:* Street Address
1785 Weyerhaeuser Road
Address Line 2
City
Vanceboro
Fbstal / Zip Code
28586-7606
Phone #:* 252-633-7427
Email Address:* [e-mail]
State / Rovince / Fbgion
NC
Country
us

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
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
Perait-holder prior to the ownership change, or perrrit-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 The
Stormwater Program at [phone] or e-mail Annette Lucas at annette.lucas(c)ncdenr.gov.

Initial Review
Project ID:* Pleviewer may revise permt nurrber here if incorrect.
NCS000211