NCG060284_Name-Owner Change Request_20221209

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 12/9/2022 12:15:46 PM (Name Owner Change Request)
Approve by Kieu Tran 12/12/2022 1:21:06 PM (Name Owner Change Review)
• The task was assigned to Kieu Tran by round robin distribution 12/9/2022 12:15 PM
The task was assigned to DEMLR SW Admin General. The due date is: January 20, 2023 5:00 PM
12/9/2022 12:15 PM

Application
Facility Name* Mayne Pharma Inc.
NPDES Permit Enter your NPDES stormwater permit number or Certificate of Coverage (COC) number.
Number* NCG060284
Begins with NCS, NCG, or NCGNE (no exposure)
Guidance for COC holders: Do not enter the General Permit number with all 0's (for example, NCG030000) but instead
your Certificate of Coverge (COC) number.
Check current owner and facility information for the permit by running a Stormwater Permit Summary Report.
Name/Owner Change Application Upload
Upload a copy of the completed and signed Permit Name/Owner Change Form below. We can begin making updates with
this submittal, but please note that you must mail in the original signed copy to our office, in accordance with
requirements in 40 CFR 122.22.
Name/Owner Change Please upload the signed "Permit Name/Owner Change Form"
Form Upload
NPDES - NAME - Owner - Change - 20221209 Re
148.85KB
submittal.pdf
pdf only
Supporting
Please upload any supporting documents (if separate from above)
Documents Upload
14.H. Project Ricky - North Carolina Special
91.6KB
Warranty Deed [Filed 10.03.22].PDF
26. Project Ricky - Ricky DivestCo Inc. - Amendment
to Certificate of Incorporation (Name Change) [Filed 509.99KB
10.03.22].PDF
pdf only
Submitter's Name
Please enter your FIRST and LAST name
Curtis Barth
Phone Number* Please enter your phone number
252-707-6335
Any format is fine.
Email Address* Please enter a valid e-mail address
[e-mail]
A confirmation of submission will be e-mailed to this address.
* By checking the box and signing below, I certify that:
I have given true, accurate, and complete information on this form;
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");
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");

I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written
signature (except for the completed Name/Owner Change Form, which also must be mailed in with original signature);
AND
I intend to electronically sign and submit this Name/Ownership Change Request form.
Signature
o` CCIrP,
Date * 12/9/2022
Questions? Contact [e-mail].

Review
Verify Permit No.* Revise permit number below if incorrect.
NCG060284
Review Date* 12/12/2022