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HomeMy WebLinkAboutNCG020749_Name-Owner Change Form_20211118Action History (UTC-05:00) Eastern Time (US & Canada) Submit by Anonymous User 11/18/2021 6:19:00 PM (Name Change Submission) Approve by McCoy, Suzanne 3/15/2022 4:26:06 PM (Review Assigned to Admin) • Georgoulias, Bethany A reassigned the task to McCoy, Suzanne 3/14/2022 4:20 PM P For training • Georgoulias, Bethany A reassigned the task to Georgoulias, Bethany A 3/13/2022 4:41 PM • The task was assigned to DEMLR SW Admin 11/18/2021 6:19 PM I� 1 NORTH CAROLINA Enrlmnmrnfat 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 -OR- General Permit Certificate of Coverage (COC) #: NCG020749 NC GX XX XX X Use this link to check the permit contact information that is currently in our database. II. Permit Status II. Permit status prior to requested change. ............................................................................................................................................................................................... a. Permit issued to:* Merritt's Gravel Pit Company Name b. Person legally responsible for permit: First name:* Middle name Tony Title: Permit holder's mailing address:* Phone #: * 919- 932- 5263 c. Facility name:* d. Facility address:* Fax #: Last name:* Merritt Street Address 3200 Damascus Church Road Address Line 2 city State / Province / Region Chapel Hill NC Postal / Zip Code Country 27516 us Merritt's Gravel Pit Street Address 3200 Damascus Church Road Address Line 2 city State / Province / Region Chapel Hill NC Postal / Zip Code Country 27516 us e. Facility contact person (prior to change, optional): First name: Middle name: Last name: Katelin Nicole Merritt Phone M (919) 448-7446 III. Requested Change Information III. Please provide the following for the requested change (revised permit). ................................................................................................................................................................................................................................................................................................................................................... a. Request for changes is a result of: * Change in ownership of facility Name Change of the facility or owner b. Permit to be issued to: * Merritt's Gravel Pit Company Name c. Person to be legally responsible for permit: First name:* Middle name: Last name: Tony Merritt Title: Permit holder's mailing address:* Street Address 3200 Damascus Church Road Address Line 2 City State / Province I Region Chapel Hill NC Postal / Zip Code Country 27516 us Phone #: * Email address:* 919- k.merritts 932- gravelpit 5263 @gmail.c om d. Faciltiy name:* Merritt's Gravel Pit Is the FACILITY contact different than the person legally responsible above?* Yes No f. Facility contact person: First name: * Middle name: Last name: Katelin Nicole Merritt Phone #: * 919-448-7446 Email address: * k.merrittsgravelpit@gmail.com IV. Permit Contact Information Is the PERMIT contact different than the person legally responsible above?* Yes No IV. Permit contact information (if different form the person legally responsible for the permit) First Name:* Middle Name: Last Name:* Katelin Nicole Merritt Title: Mailing Address: * Street Address 3200 Damascus Church Road Address Line 2 City Chapel Hill Postal / Zip Code 27516 Phone #: * 919-448-7446 Email Address: * k.merrittsgravelpit@gmail.com State / Province / Region NC Country us V. Permit Facility Activities V. Will the permitted facility continue to conduct the SAME industrial activities conducted prior to this ownership or name change: Yes No VI. Signature This completed application is required for both name change and/or ownership change requests. 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. 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 Permit -holder prior to the ownership change, or permit -holder authorizing the name change Date 3/15/2022 Initial Review Project ID: * Staff Member Email for Reminder CC of Next Step Reviewer: Revise permit number here if incorrect. NCG020749 Reviewer may revise if needed. brittany.carson@ncdenr.gov