NCG210033_Name Change Form_20180102

r Division of Energy, Mineral & Land Resources FOR AGENCY USE ONLY
4 Date Received
Land Quality Section/Stormwater Permitting I Year I Month Day
National Pollutant Discharge Elimination System
NC4R®OLI EANR
PERMIT NAME/OWNERSHIP CHANGE FORMEIXCr o N -AL
RESovnCFs
I. Please enter the permit number for which the change is requested.
NPDES Permit (or) Certificate of Coverage
2 1 3 1 4_F4 2 Q G 2 1 1 1 0 1 0 1 0 0
II. Permit status prior to requested change.
a. Permit issued to (company name): Moncure Plywood
b. Person legally responsible for permit: Brian Cullen
First MI Last
East Region Manager
Title
PO Box 1110
(803) 3854957 [e-mail]
Phone E-mail Address
IV. Permit contact information (if different from the person legally responsible for the pen -nit)
Revised Jan. 27, 2014
JA�
Permit Holder Mailing Address
Chester SC 29706
City State Zip
O�WIi�A
[phone] ( )
Phone Fax
c.
Facility name (discharge):
Moncure Plywood
d.
Facility address:
306 Corinth Road
Address
Moncure NC 27559
City State Zip
e.
Facility contact person:
Brian Van Gelder (803) 385
First / MI /Last Phone
Please provide the following for the requested
change (revised permit).
a.
Request for change is a result o£
❑ Change in ownership of the facility
® Name change of the facility or owner
If other please explain:
b.
Permit issued to (company name):
Boise Cascade Wood Products, LLC
c.
Person legally responsible for permit:
Brian Cullen
First MI Last
East Region Manager
Title
PO Box 1110
Permit Holder Mailing Address
Chester SC 29706
City State Zip
[phone] [e-mail]
Phone E-mail Address
d.
Facility name (discharge):
Boise Cascade Wood Products, LLC
e.
Facility address:
306 Corinth Road
Address
Moncure NC 27559
City State Zip
f.
Facility contact person:
Brian W Van Gelder
First MI Last
(803) 3854957 [e-mail]
Phone E-mail Address
IV. Permit contact information (if different from the person legally responsible for the pen -nit)
Revised Jan. 27, 2014

s-
NPDES PERMIT NAME/OWNERSHIP CHANGE FORM
Page 2 of 2
Permit contact: Brian W Van Gelder
First MI Last
East Region Environmental Manager
Title
306 Corinth Rd
Mailing Address
Moncure NC 27559
City State Zip
(803) 3854957 [e-mail]
Phone E-mail Address
V Will the permitted facility continue to conduct the same industrial activities conducted prior
to this ownership or name change?
® 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, Brian Cullen, 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 i plete.
12- Lz i f zal t
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 supporting information is not included, this application package will be
returned as incomplete.
Revised Jan 27, 2014
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