NCG210417_Name-Ownership Change Form_20220812

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NC DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF Energy, Mineral, and Land Resources
STORMWATER PROGRAM
NORTH CAROLINA
Environmental Quality
NPDES STORMWATER PERMIT NAME/OWNERSHIP CHANGE FORM
CURRENT PERMIT INFORMATION:
Permit Number: NCS__J__/__/__J_/_ or NCG�__Lj_ 0 J--L/? /?
1. Facility Name (prior to change): Custom Pallet & Crating, Inc.
NEW OWNER/NAME INFORMATION:
2. This request for a name change is a result of:
X a. Change in ownership of property/company
_b. Name change only (Facility and/or Company)
_c. Other (please explain):
(for example, facility address update. Include additional attachments if necessary.)
3. New owner's name (name to be put on permit as Permittee):
Inc.
4. New owner's or signing official's name and title: Curtis Brushman
(Person legally responsible for permit)
Safety Manager
(Title)
5. Mailing address: 2900 Peach Ridge Avenue NW City: Grand Rapids
State: MI Zip Code: 49543 Phone: [phone]
E-mail address: [e-mail]
6. New facility name (if applicable): Kamps Plant 1
7. Effective date of transfer or name change: July 5, 2016
�Ert North Carolina Department of Environmental Quality I Division of Energy. Mineral and Land Resources
Q� 512 North Salisbury Street 1 1612 Mail Service Center I Raleigh, North Carolina27699-1612
�s /� 919.707.9200

IV.
NPDES Stormwater Permit Name/Ownership Change
Page 2 of 2
PERMIT AND FACILITY CONTACT INFORMATION
8. New permit contact's name and title:
Curtis Brushman
(Permit Contact)
Safety Manager, Kamps Inc.
(Title)
9. Mailing address: 2900 Peach Ridge Avenue NW City: Grand Rapids
State: MI Zip Code: 49534 Phone: ( 616 ) 560-5678
E-mail address: [e-mail]
10. New facility contact's name and title: Antonio Neal
(Facility Contact)
Plant Manager
(Title)
11. Mailing address: 5104 North Graham Street
City: Charlotte
State: NC Zip Code: 28269 Phone:( 704 ) 361-3753
E-mail address: [e-mail]
12. New billing contact's name:
Curtis Brushman
(Billing Contact)
13. Mailing address: 2900 Peach Ridge Avenue NW City: Grand Rapids
State: MI Zip Code: 49534 Phone:( 616 ) 560-5678
E-mail address: [e-mail]
FACILITY ACTIVITIES AND DISCHARGE INFORMATION
1. Will industrial activities at the facility remain the same asunder the previous owner?
Yes C2 No 0
2. Will the stormwater discharge location(s) remain the same? Yes [A No 0
NOTE: if either of these questions is answered "No," then more information is needed to review
the request. Please attach documentation to describe and explain the changes to the facility
activities, stormwater discharges, and/or outfall location. Depending on the information
provided, the Division may require that the new owner file a new permit application.
Last Revised 3/13/2022

NPDES Stormwater Permit Name/Ownership Change
Page 2 of 2
THIS APPLICATION PACKAGE WILL NOT BE ACCEPTED BY THE DIVISION UNLESS
ALL OF THE ITEMS LISTED BELOW ARE INCLUDED.
REQUIRED ITEMS:
1. This completed application form (with original signature)
2. Legal documentation of transfer of ownership (such as relevant pages of a deed or a bill of sale) is
required for an ownership change request. Articles of incorporation are not sufficient for an
ownership change but can be provided for a name change.
3. Information to document facility, industrial activities, stormwater discharges, or outfall changes
as noted in item IV above (if appropriate)
Why is this information needed?
Regulations in 40 CFR §122.63 allow for minor modifications to NPDES permits for a change of
ownership or operational control of a facility, provided that information supports that no other change
in the permit are necessary.
Why does this form need to be mailed in?
Permittees and applicants must fulfill signatory requirements in the NPDES federal
regulations in 40 CFR §122.22 (please see those regulations for guidance). Until NCDEQ's
electronic submission process meets Cross -Media Electronic Reporting (CROMERR)
requirements, this original signed (not digital signature) form must be mailed to the
address below. The uploaded copy is stored as part of the permit record in the Division's
digital repository.
Applicant's Certification:
I, eevA,"An , attest that the application for a name and/or ownership
change submitted 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 package will be considered
incomplete and may be returned.
Signature: / Date: 8lgj 2 -2-
THE COMPLETED APPLICATION AND ALL SUPPORTING INFORMATION SHOULD BE SENT TO:
DEMLR Stormwater Program
512 North Salisbury Street, 61h Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
Last Revised 3/13/2022

BILL OF SALE
T141S BILL OF SALF. is executed this 5th day of July, 2016 (the "Effective Date'), by
and between CUSTOM PALLET & CRATING, INC., a North Carolina corporation of 5104
North Graham St., Charlotte, North Carolina, 28269 ("Seller") in favor of KAMPS, INC., a
Michigan corporation with its principal office located at 2900 Peach Ridge N.W., Grand Rapids
Michigan 49534 ("Buyer').
For good and valuable consideration, the receipt and sufficiency of which are
acknowledged, Seller transfers, assigns, sells and conveys to Buyer, the Other Assets of Seller as
defined and identified under the terms of the Asset Purchase Agreement between Seller and
Buyer dated July 5, 2016.
Seller warrants to Buyer and their successors and assigns, that Seller has good
title to the Assets, free and clear of all claims, liens and encumbrances.
Seller also warrants to Buyer, and its successors and assigns, that Seller will
defend the title to the Assets against all other claimants.
CUSTOM PALLET & CRATING, INC.
a North Carolina corporation
By:
James M. Gilbert, President
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