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HomeMy WebLinkAboutNCGNE1039_Name-Owner Change Form_10/31/2019Action History (UTC-05:00) Eastern Time (US & Canada) Submit by Anonymous User 10/31/2019 3:59:59 PM (Name Change Submission) Approve by McCoy, Suzanne 11/1/2019 8:23:13 AM (Notification to Admin) * NCGNE1039 • The task was assigned to McCoy, Suzanne 10/31/2019 4:00 PM � ST1V{ NORTH C:Ft iO�INA ErtYfranminlQf QYQiff}� 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) #: NCGNE0000 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: Purdue Pharma Manufacturing L.P. Company Barre b. Person legally responsible for permit: First name:* Middle name: Last name:* Donogh McGuire Title: Vice President of Technical Operations Permit holder's mailing address:* Phone #:* 252 265 1908 c. Facility name:* d. Facility address:* Fax #: Street Address 5235 International Drive Address Line 2 oty Durham Fbstal / Zip Code 27712 State / Province / Fbgion NC Country United States Purdue Pharma Manufacturing L.P. Street Address 5235 International Drive Address Line 2 oty Durham Fbstal / Zip Code 27712 e. Facility contact person (prior to change, optional): First name: Middle name: Last name: Adam Postyn Phone #: 252 265 1680 State / Province / Region NC Country Durham 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: Novo Nordisk Pharmaceutical Industries, LP Corrpany l\brre c. Person to be legally responsible for permit: First name:* Middle name Thomas Title: Permit holder's mailing address:* Phone #:* 919- 583- 2686 d. Faciltiy name: * e. Facility address:* Last name:* Schmalzb auer Street Address 5235 International Drive Address Line 2 Oty Durham Postal / Zip Code 27712 Email address:* tmsz@no vonordis k.com State / Province / Plegion NC Country USA Novo Nordisk Pharmaceutical Industries, LP Street Address 5235 International Drive Address Line 2 Oty Durham Postal / Zip Code 27712 Is the FACILITY contact different than the person legally responsible above?* r Yes f• No State / Province / Region NC Country United States IV. Permit Contact Information Is the PERMIT contact different than the person legally responsible above? f Yes r 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:* r Yes r 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 docurrentation for ownership change Novo Nordisk Deed.pdf 331.95KB Durham Property Record Search Novo 309.14KB Nordisk.pdf pdr 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. Permittee Signature F2rrrit-holder prior to the ownership change, or pernit-holder authorizing the narre 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. Applicant Signature To w horn the permt 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 (919) 707-3639 or e-mail Annette Lucas at annette.lucasCa)ncdenr.gov. Initial Review Project ID: * Fbviewer rray revise perrrit number here i incorrect. NCGNE1039