NCG160166_Name-Owner Change Application_20230612

,
NC•DEPARTMENT.OF ENVIRONMENTAL 41141.177/
fkg--
01111.510N OF Energy,Mineral,and Land Resources
•:!
STORM WATER PROGRAM
NORTH CAROLINA
Environmental Qualify
NPr.)ES.tTORIVitIVATER,PERNilT NAIVIE1OINNERSHIP CHANGE FORM
• I.. CURRENT PERMIT INFORMATION:
• Permit NUM bett / 'MGAJA/L)
1. Facility Name-(priOrto:thenge):44,a441 Cortar4OtOit 4,011eckny Int;
II. NEW OVI/NERMAME INFORIVIATIONt
2.. This request fora name changelS a result cif:
, A. Change in.ownership of propertykompanY.
NPPV,Change 001110001.1141a00./Pr OomPaPY)
ther(0100$0.60N0):
(forexample,licilityaddresLupdatre,Include additional attachments necestaty.)
3. New owner's namC(PPniev te'be.Ptit permit Petniittee):
Mc W\ibrt-
4. New owner's or signing official's nanntalid VC
0terson legally responsible for permit)
(Title)
5p address: -P.C.) . Bee, ql..k •ckit ly\pvtxco.k&N vti.st
Sotel,174 Ziptocle: 31LoS.2 Phone:•( 6123 ) toot)
-rneil address: w kr E vAmooforqxcLevirk
6. 'Nev.!facility name(if applicable): t ktr?tAk
7 Effective.date of transfer or name change:,,, 10 5/3 of,- 3
-c,tt NOT*014)018 0.eparttriVilt 1000111:41111trital OitrItY1 OftiOn of Energy,Wend artd LAW Rtsources
• .*:;) 511.14fftlh Salsbury Street I 1I2M Service Ciott Ramo,North mum 27699.110
919.70M200
. ,

NPDESStormwater'Permit Name/Ownership Change
Page 2 of 2
I'II. P ERIVIIT AN©FACILITY CONTACT INFORMATION'
8. New permit contact's-nettle and title: SEa.NN iiAAr.
(Permit Contact)
BRA SeG
(Title)
9. Mailing address: .0. y, 411
Cites v�rlau �-ry
State: `T.1, Zip Code: -a-1 to la 3 Phone:•(c1z3 ) 5`11--t 13 q
E-mail address: 5 ac etpt_ik ,ft& ..L,N.aadl. to Hn
10, New facility'contact's name and title: 5 r4r 'S Pc-any C..
(Facility Contact)
(Title)
11. Meiling.address:, City,.__......
State:,___ Zip.Code: Phone:( )
E-mall address;
12. New billing contact's name: E r5 iket.D[E
(Billing Contact)
13. Mailing address: ty:
Stater Zip Code: Phone:.':,(: }:
E-mail address
IV. FACILITY ACTIVITIES AND DISCHARGE INFORMATION
N
Will:industrial activities;at the facility remain the seine,as under the previous owner?
Yes EA No:0.
2. Will the starmwater discharge:location(s)remain the same? -Yes-Yeslif Not3
NOTE: If either of these questions is answered wAlo;"thenmore information Is needed to review
_the request Please attach documentation to describe andexplain the changes to the facility
actMVitles,storm waterdischarges,and/or outfall location Depending on the information
provided,the Division may require that the new ow,ner,'lea new,permit application.
Last Revised 3/13/2022

NPDES Storinwater Permit.Name/Ciwwnership Change
Page 2.02
MISAPPLICATION PACKAGE WILL NOT BE-ACCEPTEOoy THE DIVISION.UNLESS
ALL.Of THE ITEMS LISTED BELOW ARE-INCLUDED.
REQUIRED ITEMS:
1. This completed applicationiormm(With original signature)
2. Legal documentation of transfer of ownership(such as relevant pages of a deed or a bill ofsale)':Is
required Wan 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;Induustrial acthritles,stormwater,discharges,or outfail changes
as noted in item IV above(If appropriate)
Why is tthis information needed?
Regulations in 40 CFR§122,S3.allow for minormadifications to NPDES perrnitsfor 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 b
Permittees and applicants must fulfill signatory requirements in the NPOES federal
regulations in 40 . . (please see those regulations for guidance). Until N 3Et 's
electronic submission process meets ross edia Electronic Reporting CR ME R)
requirements, this original signed i t ore form .must be mailed to the
address below.The upl k dad copy is stored as part of the permit record in the Division's
digital repository.
1, W . p„��ic . „Attest tl'atthe;applicatiOn for a name and/or ownership
change submitted had been reviewed and Is accurate,atrd'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 isnot included,this application package Will be considered
incomplete and may be returned:,
Signature,
Date: 1202,3
20
THE COMPLETED.APPI ICATION ANIYALL SUPPORTING°INFORMATION SHOULD BE SENT To:
DEMLR storm tern PrOgrarri
59:2.North Salisbury Sttre t,:6th Floor(Office 640K)
16 "Mail Service Centeer
Leigh,NC,:0604612
(At Revised 3/13/2022