NCG030675_Name-Change

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Division of Energy, Mineral & Land Resources
FOR AGENCY USE ONLY
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Land Quality Section/Stormwater Permitting
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Date MontRe.h
Year Month Day
II
NCDENR
National Pollutant Discharge Elimination System
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PERMIT NAME/OWNERSHIP CHANGE FORM
c. Person legally responsible for permit:�ci
I. Please enter the permit number for which the change is requested.
NPDES Permit (or) Certificate of Coverage
N I C I S 10 1 1 N C I G 10 13 10 1 Io 1 7 51
II. Permit status prior to requested change.
a. Permit issued to (company name): AmetiCAi) einec�.. V A cl-s
b. Person legally responsible for permit: Kc -%t' SAQkM
First MI Last
Title
/o/ AE✓ LAOf (froit",G, 19A" L,wc)
Permit Holder Mailing Address
SCj;�uSDA A)c 2g&go
City State Zip
( 3% ) 8 -1372 (336) cm -CIM
Phone Fax
c. Facility name (discharge):I�EV I�ie Mov.s1 L
d. Facility address: /01 &V LANF (fsRnnell,� GADS A4r
Address
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City State Zip
e. Facility contact person: 14et.4 &44 EIL (334) 841/- t37Z
IV. Permit contact information (if different from the person legally responsible for the permit)
Revised Jan. 27, 2014
First / MI /Last Phone
III. Please provide the following for the requested change (revised permit).
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: Cei�[tCt�
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b. Permit issued to (company name):
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c. Person legally responsible for permit:�ci
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MI Last
First Mi
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ut2fc_108. of
Title
/GS AMuttcAN YJAc=
Permit Holder Mailing Address
7egia& , NC 2ewta
City State Zi
(3m )8g&-8010 A.cReyc!' _ ccev.Can
Phone t� /a E-mail Address
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d. Facility name (discharge):
M ow.rl C en+ uL
e. Facility address:
/p/ A£V IAAhr
Address
T24 r(eAS&A n)L 2Sa1T
City State \Zip
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f Facility contact person:
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First MI Last
(3 ) 8rf4• gpA9 •, ,'d reterQcue V.Com
Phone E-mail Address
IV. Permit contact information (if different from the person legally responsible for the permit)
Revised Jan. 27, 2014

NPDES PERMIT NAME/OWNERSHIP CHANGE FORM
Page 2 of 2
Permit contact: �� loto2
First MI Last
jN,4ez4VR 4F
Title
I6S pi�wCA+% h%A�
Mailing Address
OZ -4- -bf�eR A)L 21660
City State q
('� ) fpS((e^80/0 'i e,�, d iYy eRl�'L. CW+%
Phone E-mail Address
V Will the permitted facility continue to conduct the same industrial activities conducted prior
to t4is ownership or name change?
Yes
❑
No (please explain) 600et-6k1p wea faeoAxe.I 00+Ehh'JoD•
VI. Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS
ARE INCOMPLETE OR MISSING:
❑ This completed application is required for both name change and/or ownership change
requests.
❑ 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.
..................................................................................................................
The certifications below must be completed and signed by both the permit holder prior to the change, 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 o owledge. I understand that if all required parts of this application are not
completed and that if all require orting information is not included, this application package will be
returned as incomnletee
i2- //- /Y
Signature Date
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 supporting information is not included, this application package will be
returned as incomplete.
Signature
Date
PLEASE SEND THE COMPLETE APPLICATION PACKAGE TO:
Division of Energy, Mineral and Land Resources
Stormwater Permitting Program
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
Revised Jan. 27, 2014