NCG070214_Name-Owner Change Application_20230301

ic:orlD Division of Energy, Mineral, and Land Resources
;� "!\ �✓ Land Quality Section / Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
PERMIT OWNER AFFILIATION DESIGNATION FORM
(Individual Legally Responsible for Permit)
Use this form if there has been:
FOR AGENCY USE. ONLY
Date Recei�vd
Year
A!o"At
Pay
NO CHANGE in facility ownership or facility name, but the individual
who is legally responsible for the permit has changed.
If the name of the facility has changed, or if the ownership of the facility has changed,
do NOT use this form. Instead, you must rill out a Name -Ownership Change Form
and submit the completed form with all required documentation.
What does "legally responsible individual" mean?
The person is either:
• the responsible corporate officer (for a corporation);
• the principle executive officer or ranking elected official (for a municipality, state, federal or other public
agency);
• the general partner or proprietor (for a partnership or sole proprietorship);
• or, the duly authorized representative of one of the above.
I) Enter the permit number for which this change in Legally Responsible Individual ("Owner Affiliation")
applies:
Individual Permit (00 Certificate of Coverage or No Exposure
N C S I I I I N I C I G 10 17 10 12 11 4
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
Trulite Aluminum and Glass Solutions
285 Northbrook Drive
Address
Youngsville NC 27596
city slate zip
To find the current legally responsible person associated with your permit, go to this website:
littps:Hdeg.nc.gov/sw/ Navigate to the "NPDES Industrial Program" section and run the Stotnuwater Permit
Contact Summary Report for your permit number.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Jeremy
Hoy
First lull Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: JD Oosthuizen
First ml Last
Page I of 2
Last revised 20 Feb 2022

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
Operations Manager
Title
285 Northbrook Drive
Mailing Address
Youngsville NC 27596
city state zip
( 919 ) 435-3050 [e-mail]
Telephone E-mail Address
Fax Number
5) Reason for (his change:
A result of: E] Employee or management change
❑ inappropriate or incorrect designation before
❑ Other
If rather please explain:
The certification below must be completed and signed by the permit holder.
Note: 40 CFR 122.22(c) requires an original signature (not digital)
PERMITTEE CERTIFICATION:
1, JD Oosthuizen , attest that this application for this change in Owner Affiliation
(person legally responsible for the permit) has been reviewed and is accurate and complete to the best of
my knowledge. I understand that if all required parts of this form are not completed, this change may not
be processed.
3/1/2023
Signature Date
PLEASE SEND THE ORIGINAL SIGNED COPY OF THE COMPLETED
OWNER AFFILIATION CHANGE FORM TO:
DEMLR - Stormwater Program
Dept. of Environtnental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
For more information or staff contacts, please call [phone] or visit the website
at: iittp://deg.iic.gov/sw
Per NC General Statute 143-215.6E (i), 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 sliall be guilty of a Class 2 misdemeanor which may include a fine not to
exceed ten thousand dollars ($I0,000).
Page 2 of 2
Last revised 20 Feb 2022

~% NC DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF Energy, Mineral, and Land Resources
STORMWATER PROGRAM
NORTH CAROLtNA
Environmental Quality
NPDES STORMWATER PERMIT NAME/OWNERSHIP CHANGE FORM
I. CURRENT PERMIT INFORMATION:
Permit Number: NCS___/��_/_/^ or
1. Facility Name (prior to change): Trulite Glass and Aluminum Solutions
II. NEW OWNER NAME INFORMATIOW
2. This request for a name change is a result of:
a. Change in ownership of property/company
b. Name change only (Facility and/or Company)
X c. Other (please explain): Permit and facifty contact information
(for example, facility address update. include additional attachments if necessary.)
3. New owner's name (name to be put on permit as Permittee):
4. New owner's or signing official's name and title:
(Person legally responsible for permit)
5. Mailing address:
State: Zip Code: Phone: (
E-mail address:
6. New facility name (if applicable):
7. Effective date of transfer or name change:
City:
(Title)
�North Carolina Departwnk of Environmental Qualil y I Etivislon of Energy. Mlnrral and Land Resources
N! 1 _'lq:�!'JrJq/ 512 North Salisbury Street I W2 Mall Service Center I Raleigh. North Carolina 27699-1612
� 919.707R200

NPDES Stormwater Permit !Name/Ownership Change
Page 2 of 2
III. PERMIT AND FACILITY CONTACT INFORMATION
8. New permit contact's name and title: Christopher Franco
(Permit Contact)
EH5 Manager
(Title)
9. Mailing address: 285 Northbrook Drive city: Youngsville
State: NC Zip Code: 27596 Phone: ( 919 ) 435-3050
E-mail address: cfranceCcD_tru1ite.com
10. Newfacility contact's name and title:
State:
E-mail address:
(Facility Contact)
(Title)
M
Zip Code: Phone: ( )
12. New billing contact's name: _
13. Mailing address:
State: Zip Code:
E-mail address:
(Billing Contact)
City:
Phone:(
IV. FACILITY ACTIVITIES AND DISCHARGE INFORMATION
1. Will industrial activities at the facility remain the same asunder the previous owner?
Yes ® No 11
2. Will the stormwater discharge location(s) remain the same? Yes® NOD
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 ownerfile 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, Christopher France , 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 suppo g i for r}r a is not included, this application package will be considered
incomplete,odd ma -/.tdrned.
Date: 3/1 /2023
THQCOfyl PLVED APPLICATION AND ALLSUPPORTING INFORMATION SHOULD BE SENT TO:
DEMLR Stormwater Program
512 North Salisbury Street, 6th Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
Last Revised 3/13/2022