NC0023442_Owner Name Change_20170717

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NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Resources
Pat McCrory Donald R van der Vaart
Governor WATER QUALITY PERMITTING SECTION Secretary
PERMIT NAME/OWNERSHIP CHANGE REQUEST
This form is for ownership changes or name changes of NPDES wastewater permits.
• "Permittee" references the existing permit holder
• "Applicant" references the entity applying for the ownership/name change.
I. NPDES Permit No. (for which the change is requested): N C 0 0 2
3 4 4 2
or
Certificate of Coverage #:
N C G 5
II. Existing Permittee Information:
a Permit issued to (company name)
Boise Cascade Wood Products, LLC
b Person legally responsible for permit
Thomas A
Lovlien
First MI
Last
President
Title
RECEIVEDINCDEQIDWR
Permit Holder Mailing Address
JUL 17 2017
Boise ID
83702-
City State
City
Zip
Water Quality
Permitting Section
( ) 384-6142
( )
Phone
Fax
c Facility name
Moncure Plywood
d Facility's physical address
306 Corinth Road
Address
Moncure NC
27559 -
City State
Zip
e Facility contact person
Brian W Van Gelder
[phone]
First / MI / Last
Phone
III. Applicant Information:
a Request for change is a result of ❑ Change in ownership of the facility
® Name change of the facility or owner
If other please explain
b Permit issued to (company name)
c Person legally responsible for permit.
RECEIVEDINCDEWWR
JUL 17 2011
Water Quality
ecion
Permitting
Page I of 2
Boise Cascade Wood Products, LLC
Daniel Hutchinson
First MI Last
Executive Vice President
Title
1111 West Jefferson St
Permit Holder Mailing Address
Boise ID 83702 -
City State Zip
(208) 3846302 DanielHutchinsonpbc com
Phone E-mail Address
Revised 7/01/2014

• � I—
d. Facility name Moncure Plywood
e Facility's physical address 306 Corinth Rd
Address
Moncure NC 27559 -
City State Zip
f. Facility contact person. Brian W Van Gelder
First MI Last
Eastern Regional Environmental Manager
Title
[phone] BrianVanGelder(a bc,com
Phone E-mail Address
IV. Will the permitted facility continue to conduct the same commercial/industrial activities conducted prior to
this ownership or name change?
® Yes
❑ No (please explain)
If applicable, the applicant shall submit a major permit modification request to DWR A mayor modification shall be
defined as one that increases the volume, increases the pollutant load, results in a significant relocation of the
discharge point, or results in a change in the characteristics of the waste generated
V. Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS ARE
INCOMPLETE OR MISSING:
1 This completed application is required for both name change and/or ownership change requests
2. Legal documentation of the transfer of ownership (such as relevant pages of a contract deed, or a bill of sale) is
required for an ownership change request Articles of incorporation are not sufficient for an ownership change
Applicable regulations 40 CFR 122 41, 40 CFR 122 61 and 15A NCAC 02H 0114
.....................................................................................................................
The certifications below must be completed and signed by both the permit holder prior to the change (Permittee), and the
new applicant in the case of an ownership change request For a name change request, the signed Applicant's Certification
is sufficient
PERMITTEE CERTIFICATION (Permit holder prior to ownership change).
I, , attest that this application for a name/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 and that if all required
supporting information is not included, this application package will be returned as incomplete
Signature
Date
APPLICANT CERTIFICATION
I, , attest that this application for a name/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 and that if all required
su ortmg information is not included, this application package will be returned as incomplete.
Signature
Date
PLEASE SEND THE COMPLETE APPLICATION PACKAGE TO:
Division of Water Resources
Water Quality Permitting Section
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
NPDES PERMIT NAME/OWNERSHIP CHANGE REQUEST
Page 2 of 2
Revised 7/01/2014