NCG030469_Name Ownership Change_20171121

Division of Energy, Mineral & Land Resources I FOR AGENCY USE ONLY
Date Received
Land Quality Section/Stormwater Permitting Year Month Day
L National Pollutant Discharge Elimination System
NCDENR [RtU---_1V�71
No— G- Dew�Rrnerrt or =• i.y,. C
ENVIR0- AND NRVRAL RESOURCES PERMIT NAME/OWNERSHIP CHANGE FORM
NOV 21 2011
I. Please enter the permit number for which the change is requested. n fric QUnl I I
l r� 5 .r. -'"
NPDES Permit (or) Certificate rO&,Mrage. ;E.-, 10..;
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II. Permit status prior to requested change.
a. Permit issued to (company name): �;� ��s�m CQrnpor�e�cs
b. Person legally responsible for permit: Qdp rr,r� �h
First MI Last
P1o,ht M0.Y�ClgpY
Title°
-�3o\ N Lkat(\S-rreet.
Permit Holder Mailing Address
T'rt 1ryaorn NC 9__-b8(0
City State Zip
(252 ) G 4 1 - 541S ( )
Phone Fax
c. Facility name (discharge): (, tr)Y-fN9u\�rL�
d. Facility address: m cath Sire C -t
Address
'TC7,Yb0r0 NC
City State Zip
e. Facility contact person: �hctve k 4 iA)(tShiy�QTon (2,;�_ ) i041 -E913
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:
b. Permit issued to (company name):
c. Person legally responsible for permit:
Facility name (discharge)
e. Facility address:
f. Facility contact person:
)0hnS0n 0,0v)1-fols
Vv(\liom Kcr1-pQ"tri cK
First MI Last
F`�\CLV�f t'�lL�Y1QGEY
Title
Permit Holder Mailing Address
1hy-knk-x k) Q 9-1276L
City State Zip
(2F:)2 ) (D4k — rJCA 10" WiMOLM .1. k%0 -P 3.'iY�COP jCi -COM
Phone E-mail Address
tJ . Y• l Clio SbfCe kZ
Address
taYboft MC 2R58U
City State Zip
--ray-o'. N C-aTr
First MI Last
(Sroz ) (oqF —Sng3 ta1rQ . in xarda" ac' covn
Phone E-mail Address
IV. Permit contact information (if different from the person legally responsible for the permit)
Revised Jan 27, 2014 OfN

L (�
NPDES PERMIT NAME/OWNERSHIP CHANGE FORM
Page 2 of 2
Permit contact:
First MI Last
Title
Mailing Address
City State Zip
Phone E-mail Address
V Will the permitted facility continue to conduct the same industrial activities conducted prior
two this ownership or name change?
Ley- Yes
❑ No (please explain)
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 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, -ft—, 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 s porting information is not included, this application package will be
retur d as incomplete.
/0- -3 17
ignature Date
Revised Jan 27, 2014
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