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HomeMy WebLinkAboutNCG080318_Name-Owner Change Form_5/18/2020Action History (UTC-05:00) Eastern Time (US & Canada) Subrrit by Anonymous User 5/18/2020 9:51:22 AM (Name Change Submission) Approve by McCoy, Suzanne 5/26/2020 3:18:10 PM (Notification to Admin) • The task was assigned to McCoy, Suzanne 5/18/2020 9:51 AM 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) #: NCG080318 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: Wilson Trucking Conpany I brre b. Person legally responsible for permit: First name:* Middle name: Last name:* Gerry Horn Title: Director of Property Management Permit holder's mailing address:* Phone #:* 206- 818- 4676 c. Facility name:* d. Facility address:* Fax #: Street Address 3450 S 59th Avenue Address Line 2 C7ty State / Rovince / Fbgion Phoenix AZ Fbstal / Zip Code Country 85043 us Central Freight Lines, Inc Street Address 1504 Rock Barn Road Address Line 2 C7ty State / Rovince / Region Conover NC Fbstal / Zip Code Country 28613 us e. Facility contact person (prior to change, optional): First name: Middle name: Last name: 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:* Central Freight Lines, Inc Company femme c. Person to be legally responsible for permit: First name:* Middle name: Last name:* Gerry Horn Title: Director of Property Management Permit holder's mailing address:* Street Address 3450 S 59th Avenue Address Line 2 city Phoenix Rbstal / Zip Code 85043 Phone #:* Email address:* 206- ghorn@c 818- entralfrei 4676 ght.com d. Faciltiy name:* Central Freight Lines, Inc Is the FACILITY contact different than the person legally responsible above?* r Yes r No f. Facility contact person: First name: Rick Phone #:* Middle name 704-472-8774 Email address:* rmoore@centralfreight.com Last name:* Moore State / Province / Region AZ Country us IV. Permit Contact Information Is the PERMIT contact different than the person legally responsible above?* r Yes l: 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 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. 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 Perait-holder prior to the ownership change, or pernit-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(a)ncdenr.gov. Initial Review Project ID:* Pleviewer may revise permt nurrber here if incorrect. NCGO80318