NCS000107_SW Permit DOSA (Wrong Form)_20230828

11/9/2020 Submission Completed
(210 NPDES Permit Name/Ownership Change Request
NORTH CAROLINA.
Environmental Quality
I. Permit Information
I. Please enter the permit number for which the change is requested.
NPDES Stormwater Individual Permit#: NCS000107
Begins with NCS
- OR-
General Permit Certificate of Coverage (COC) #: Begins with NCG or NCGNE
(no exposure)
Use this link to check the permit contact information that is currently in our database.
https://edocs.deq.nc.gov/Forms/Form/Submit 1/7

11/9/2020 Submission Completed
II. Permit Status
II. Permit status prior to requested change.
a. Permit issued to:* Lanxess Corporation
�ompany Name
b. Person legally responsible for permit:
First name:* Middle name: Last name:*
Michael Vancil
Title: Plant Manager
Permit holder's mailing address:* Street Address
520 Broome Road
Address Line 2
City State/Province/Region
Greensboro NC
Postal/Zip Code Country
27406 USA
Phone #:* Fax#:
336-378-0965
c. Facility name:* Lanxess Corporation
d. Facility address:* Street Addres,
520 Broome Road
Address Line 2
City State/Province/Region
Greensboro NC
Postal/Zip Code
27406 USA
e. Facility contact person (prior to change, optional):
First name: Middle name: Last name:
Michael Vancil
https://edocs.deq.nc.gov/Forms/Form/Submit 2/7

11/9/2020 Submission Completed
Phone #: [phone]
https://edocs.deq.nc.gov/Forms/Form/Submit 3/7

11/9/2020 Submission Completed
III. Requested Change Information
III. Please provide the following for the requested change (revised permit).
a. Request for changes is a result Change in ownership of facility
of:* Name Change of the facility or owner
b. Permit to be issued to:* Lanxess Corporation
,ompany Name
c. Person to be legally responsible for permit:
First name:* Middle name: Last name:*
LaBarron McMillian
Title: Plant Manager
Permit holder's mailing address:* Street Addres
520 Broome Road
Address Line 2
City State/Province/Region
Greensboro NC
Postal/Zip Code 'ountry
336-378-0965 USA
Phone #:* Email address:*
336-378-0965 [e-mail]
d. Faciltiy name:* Lanxess Corporation
Is the FACILITY contact different than the person legally responsible above?* Yes
No
https://edocs.deq.nc.gov/Forms/Form/Submit 4/7

11/9/2020 Submission Completed
IV. Permit Contact Information
Is the PERMIT contact different than the person legally responsible above?* Yes
No
https://edocs.deq.nc.gov/Forms/Form/Submit 5/7

11/9/2020 Submission Completed
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
https://edocs.deq.nc.gov/Forms/Form/Submit 6/7

11/9/2020 Submission Completed
VI. Signature
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.
This completed application is required for both name change and/or ownership change requests.
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*
JirS;rtt w 1/?a
Permit-holder prior to the ownership change,or permit-holder authorizing the name
change
Will another person need to complete or sign this form before it can be submitted? No problem! Simply CLICK
the "Save as Draft" button below and send the URL link to the other party to access the form. Questions? Call The
Stormwater Program at [phone] or e-mail Annette Lucas at [e-mail].
https://edocs.deq.nc.gov/Forms/Form/Submit 7/7