NCG070146_Name-Ownership Change Request_4/12/2018

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) #:
NCG070146
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: Kings Mountain Mining, Inc.
ConpanyWre
b. Person legally responsible for permit:
First name: Middle name: Last name:
Peter Flynn
Title:
Permit holder's mailing address: Street Address
PO Box 1668
Address Line 2
aty
Kings Mountain
Fbstal / Zip Code
28086
Phone #: Fax #:
704- 704-
734- 739-
3515 3713
State / Province / Fbegion
nc
Country
USA
c. Facility name: Kings Mountain Mining, Inc.- Battleground
d. Facility address: Street Address
1214 South Battleground Avenue
Address Line 2
aty State / Province / Fbgion
Kings Mountain NC
Fbstal / Zip Code Country
28086 US
e. Facility contact person (prior to change, optional):
First name: Middle name: Last name:
Peter Flynn
Phone #: [phone]

III. Requested Change Information
111. Please provide the following for the requested change (revised permit).
a. Request for changes is a result of: r Change in ownership of facility
r Name Change of the facility or owner
b. Permit to be issued to: Imerys Mica Kings Mountain, Inc.
Company Nlarre
c. Person to be legally responsible for permit:
First name: Middle name: Last name:
Joel Ventura
Title: Operations Manager
Permit holder's mailing address: Street Address
P.O. Box 1668
Address Line 2
aty
Kings Mountain
Fbstal / Zip Code
28086
Phone #: Email address:
450- joel.vent
655- ura@ime
2450 rys.com
d. Faciltiy name: Battleground
Is the FACILITY contact different than the person legally responsible
above?
r Yes
r No
f. Facility contact person:
First name: Middle name: Last name:
Michael Henders
on
Phone #: [phone]
Email address: [e-mail]
State / F rovince / Fbgion
NC
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 formthe person legallyresponsible for the
.................................................................................................................................
First Name: Middle
Last Name:
Michael Name:
Henders
on
Title:
Production Manager
Mailing Address:
Street Address
P.O. Box 1668
Address Line 2
aty
Kings Mountain
F bstal / Zip Code
28086
Phone #: [phone]
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, signed certifications must be completed 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.
Signed Certification Upload A signed certif ication staterrent is required
Battleground Applicant Certification Joel
378.89KB
Ventura Executed.pdf
pdf only

Initial Review
Project ID:* NCG070146