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HomeMy WebLinkAboutNCG080828_Name-Owner Change Form_20220204Action History (UTC-05:00) Eastern Time (US & Canada) Submit by Anonymous User 2/4/2022 2:19:59 PM (Name Change Submission) Approve by Georgoulias, Bethany A 3/25/2022 9:59:26 AM (Review Assigned to Admin) * Discussed with Matt Einsmann on 3/25/2022 by phone. Republic Services LLC is set up as a group of owner entities in BIMS, and this facility will now be associated with "Republic Services of North Carolina LLC - Troy" (which has Billy Maness designated as the legally responsible official). Revised facility owner in BIMS on 3/25/2022 and added other contacts. • Georgoulias, Bethany A assigned the task to Georgoulias, Bethany A 3/21/2022 3:23 PM • The task was assigned to DEMLR SW Admin 2/4/2022 2:20 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) #: NCG080828 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:* Republic Services of North Carolina LLC - Raleigh Company Name b. Person legally responsible for permit: First name:* Middle name: Last name:* Joseph Dehner Title: General Manager Permit holder's mailing address:* Phone #: * 919- 868- 2195 c. Facility name:* d. Facility address:* Fax #: Street Address 2477 U.S. Highway 301 North Address Line 2 city State / Province / Region Dunn NC Postal / Zip Code Country 28335 US Republic Waste Services - DUnn Street Address 2477 U.S. Highway 301 North Address Line 2 city State / Province / Region Dunn NC Postal / Zip Code Country 28335 US e. Facility contact person (prior to change, optional): First name: Middle name: Last name: Michael Novicky Phone M 910-477-8282 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: * Republic Services of North Carolina, LLC - Troy Company Name c. Person to be legally responsible for permit: First name:* Middle name: Last name: William Manness Title: General Manager Permit holder's mailing address:* Street Address 1137 Albemarle Rd Address Line 2 City State / Province / Region Troy NC Postal / Zip Code Country 27371 us Phone #: * Email address:* 910-606- wmaness 3183 @republi cservices .com d. Faciltiy name:* Republic Waste Services - Dunn Is the FACILITY contact different than the person legally responsible above?* Yes No f. Facility contact person: First name: * Middle name: Last name:* Joseph Dehner Phone #: * 919-868-2195 Email address: * jdehner@republicservices.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:* Joseph Dehner Title: Operations Manager Mailing Address:* Street Address 2477 U.S.301 Address Line 2 City State / Province / Region Dunn NC Postal / Zip Code Country 28335 US Phone #: * 919-868-2195 Email Address: * jdehner@republicservices.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: 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 12tzlssr 0 6Q Permit -holder prior to the ownership change, or permit -holder authorizing the name change Date 3/25/2022 Initial Review Project ID: * Staff Member Email for Reminder CC of Next Step Reviewer: Revise permit number here if incorrect. NCG080828 Reviewer may revise if needed. brittany.carson@ncdenr.gov