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HomeMy WebLinkAboutNCG020310_Name-Owner Change Form_20210331Action History (UTC-05:00) Eastern Time (US & Canada) Submit by Anonymous User 3/31/2021 4:06:51 PM (Name Change Submission) Approve by McCoy, Suzanne 4/15/2021 8:23:56 AM (Notification to Admin) • The task was assigned to McCoy, Suzanne 3/31/2021 4:06 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) #: NCG020310 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: Carolina Quarries, Inc Conpany f brre b. Person legally responsible for permit: First name:* Middle name: Last name:* Cedric Amar Title: Chief Operating Officer Permit holder's mailing address:* Phone #:* 70463 66780 c. Facility name:* d. Facility address:* Fax #: Street Address 805 Harris Granite Road Address Line 2 C7ty State / Rovince / Fbgion Salisbury NC Fbstal / Zip Code Country 28146 us Gardenia White Quarry Street Address 3399 Earnhardt Rd Address Line 2 C7ty State / Rovince / Fbgion Rockwell NC Fbstal / Zip Code Country 28138-8539 us e. Facility contact person (prior to change, optional): First name: Middle name: Last name: Robbie Holshous er 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:* Vulcan Construction Materials, LLC Company %rre c. Person to be legally responsible for permit: First name:* Middle name: Last name:* Sean Hawley Title: Vice President & General Manager Permit holder's mailing address:* Street Address 4401 North Patterson Avenue Address Line 2 city State / Province / Region Winston-Salem NC Rbstal / Zip Code Country 27105-1638 us Phone #:* Email address:* 33676 hawleys 74600 @vmcma il.com d. Faciltiy name:* Gardenia White Quarry e. Facility address:* Street Address 3399 Earnhardt Rd Address Line 2 City State / Province / Region Rockwell NC Rbstal / Zip Code Country 28138-8539 us 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:* Butch Newby Phone #:* 7042795567 Email address:* newbyb@vmcmail.com 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:* Tony Name: johnson Title: Mailing Address:* Street Address 11020 David Taylor Dr Address Line 2 Suite 400 City State / R'ovince / Region Charlotte North Carolina Fbstal / Zip Code Country 28262 United States Phone #:* 7045477076 Email Address:* johnsonto@vmcmail.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. 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 Gardenia NPDES Letter signed.pdf 20.6KB Gardenia White Quarry Carolina Quarries 44.74KB INC NPDES Permit - CA.pdf pdt 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 ��' ca�dcr �sv�gyvr rsrm�-r,rq Pernit-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. 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 w horn the permt is to be transferred Will another person need to complete or sign this form before it can be submitted? IVo 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.lucasa-ncdenr.gov. Initial Review Project ID:* Pleviewer may revise permt nurrber here if incorrect. NCG020310