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HomeMy WebLinkAboutNCGNE1195_Name-Owner Change Form_12/5/2019Action History (UTC-05:00) Eastern Time (US & Canada) Subrrit by Anonymous User 12/5/2019 3:48:13 PM (Name Change Submission) Approve by McCoy, Suzanne 12/13/2019 1:11:44 PM (Notification to Admin) • The task was assigned to McCoy, Suzanne 12/5/2019 3:48 PM NORTH CAROLINA EmlmnmerrW 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 WTZIE General Permit Certificate of Coverage (COC) #: NCGNE1195 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: Amazon.com Services, Inc. Cor pany Wre b. Person legally responsible for permit: First name:* Middle name: Last name:* Kevin Winston Title: Global Environmental Field Leader Permit holder's mailing address:* Phone #:* (925) 577- 5326 c. Facility name:* d. Facility address:* Fax #: Street Address P.O. Box 80842 Address Line 2 ATTN: E. Chapman C ly State / Rovince / Fbgion Seattle Washington Fbstal / Zip Code Country 98108 United States Amazon.com Services, Inc. - CLT5 Street Address 1745 Derita Road Address Line 2 C7ty State / Rovince / Fbgion Cabarrus North Carolina Fbstal / Zip Code Country 28027 United States e. Facility contact person (prior to change, optional): First name Phone #: Middle name: Last name: 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:* Amazon.com Services, LLC Conpany %rre c. Person to be legally responsible for permit: First name:* Middle name: Last name:* Kevin Winston Title: Global Environmental Field Leader Permit holder's mailing address:* Street Address P.O. Box 80842 Address Line 2 ATTN: E. Chapman city Seattle Rbstal / Zip Code 98108 State / Province / Region Washington Country United States Phone #:* Email address:* (925) winskevi 577- @a mazo 5326 n.com d. Faciltiy name:* Amazon.com Services, LLC - CLT5 Is the FACILITY contact different than the person legally responsible above?* r Yes r No f. Facility contact person: First name: Eric Phone #:* Middle name (206)413-4526 Email address:* echapm@amazon.com Last name:* Chapma n IV. Permit Contact Information Is the PERMIT contact different than the person legally responsible above?* r Yes No IV. Permit contact information (if different form the person legally responsible for the permit) First Name:* Middle Last Name:* Eric Name: Chapma n Title: Environmental Program Manager Mailing Address:* Street Address P.O. Box 80842 Address Line 2 ATTN: E. Chapman City State / Frovince / Region Seattle Washington Fbstal / Zip Code Country 98108 United States Phone #:* (206) 413-4526 Email Address:* echapm@amazon.com 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 Fixrrit-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 (919) 707-3639 or e-mail Annette Lucas at annette.lucas(c)ncdenr.gov. Initial Review Project ID:* Reviewer may revise permt nurrber here if incorrect. NCGNE1195