NCG020158_Name-Owner Change Form_20211008

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 10/8/2021 4:02:10 PM (Name Change Submission)
Approve by McCoy, Suzanne 10/15/2021 1:14:36 PM (Notification to Admin)
• The task was assigned to McCoy, Suzanne 10/8/2021 4:02 PM

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1
NORTH CAROLINA
Enrlmnmrnfat Quality
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) #:
NCG020158
NC
GX
XX
XX
X
Use this link to check the permit contact information that is currently in our database.

II. Permit Status
II. Permit status prior to requested change.
.....................................................................................................................................................................................................
a. Permit issued to:* Ararat Rock Products Company
Company Name
b. Person legally responsible for permit:
First name:* Middle name: Last name:*
James Crossing
ham
Title:
Permit holder's mailing address:* Street Address
PO Box 988
Address Line 2
City
State / Province / Region
Mount Airy
NC
Postal / Zip Code
Country
27030
us
Phone #: * Fax M
336- 336-
786- 786-
2680 2189
c. Facility name:*
Ararat Rock Products Company
d. Facility address:*
Street Address
525 Quarry Road
Address Line 2
City
State / Province I Region
Mount Airy
NC
Postal / Zip Code
Country
27030
us
e. Facility contact person (prior to change, optional):
First name: Middle name: Last name:
James Crossing
ham
Phone M 336-786-2680

III. Requested Change Information
III. Please provide the following for the requested change (revised permit).
a. Request for changes is a result of: * Change in ownership of facility
Name Change of the facility or owner
b. Permit to be issued to: * Luck Stone Corporation
Company Name
c. Person to be legally responsible for permit:
First name:* Middle name: Last name:*
Mark Williams
Title: Environmental Manager
Permit holder's mailing address: *
Phone #:
804-
476-
6404
d. Faciltiy name:*
e. Facility address:*
Email address:*
markdwill
iams@lu
ckcompa
nies.com
Street Address
POBox 29682
Address Line 2
City
State / Province / Region
Richmond
Virginia
Postal / Zip Code
Country
23242
United States
Luck Stone - Mount Airy Plant
Street Address
525 Quarry Road
Address Line 2
City
State / Province / Region
Mt Airy
NC
Postal / Zip Code
Country
27030
us
Is the FACILITY contact different than the person legally responsible above?*
Yes
No

IV. Permit Contact Information
Is the PERMIT contact different than the person legally responsible above?*
Yes
No

V. Permit Facility Activities
V. Will the permitted facility continue to conduct the SAME industrial activities conducted prior to this ownership
or name change:
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.
Legal documentation of transfer of ownership (such as relevant pages of a contract deed, or a bill of sale)
is required for an ownership change request. Articles of incorporation are not sufficient for an ownership
change.
File Upload:* Upload supporting documentation for ownership change
DOC 21 1006 Transfer of permit
73.42KB
NCG020158.pdf
pdf only
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.
In addition, I agree that submission of this form is a "transaction" subject to Chapter 66, Article 40 of the NC General
Statutes (the "Uniform Electronic Transactions Act"); and I agree to conduct this transaction by electronic means pursuant
to Chapter 66, Article 40 of the NC General Statutes (the "Uniform Electronic Transactions Act');
Permittee Signature
Permit -holder prior to the ownership change, or permit -holder authorizing the name change
Applicant 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.
In addition, I agree that submission of this form is a "transaction" subject to Chapter 66, Article 40 of the NC General
Statutes (the "Uniform Electronic Transactions Act"); and I agree to conduct this transaction by electronic means pursuant
to Chapter 66, Article 40 of the NC General Statutes (the "Uniform Electronic Transactions Act');
Applicant Signature
To whom the permit is to be transferred
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 [e-mail].

Initial Review
Project ID: *
Staff Member Email for Reminder CC
of Next Step
Reviewer: Revise permit number here if incorrect.
NCG020158
Reviewer may revise if needed.
[e-mail]