NCS000456_CC SW Ownership Change_20180713

Please enter the permit number for which the change is requested.
NPDES Permit (or) Certificate of Coverage
0 0 4 5 6
Permit status prior to requested change.
a. Permit issued to (company name): Cove City Wood Preserving Inc
b. Person legally responsible for permit: Jane House
First MI Last
Title
11065 Old Hwy 70 West
Permit Holder Mailing Address
Cove City NC 28523
City State Zip
[phone] ( )
Phone Fax
c. Facility name (discharge): Cove City Wood Preserving Inc
d. Facility address: 11065 Old Hwy 70 West
Address
Cove City NC 28523
City State Zip
e. Facility contact person: Jane House [phone]
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
!f other please explain:
b. Permit issued to (company name): Culpeper of Cove City, LLC
c. Person legally responsible for permit: Josh Adkins
First MI Last
Division of Energy, Mineral & Land Resources
FOR AGENCY USE ONLY
�,
ATA
Land Quality Section/Stormwater Permitting
nate Reae.al
Yea, 11Monty 11 Da
NCDENR
National Pollutant Discharge Elimination System
­­-
PERMIT NAME/OWNERSHIP CHANGE FORM
[phone] jadkins(&culpeperwood.com
Please enter the permit number for which the change is requested.
NPDES Permit (or) Certificate of Coverage
0 0 4 5 6
Permit status prior to requested change.
a. Permit issued to (company name): Cove City Wood Preserving Inc
b. Person legally responsible for permit: Jane House
First MI Last
Title
11065 Old Hwy 70 West
Permit Holder Mailing Address
Cove City NC 28523
City State Zip
[phone] ( )
Phone Fax
c. Facility name (discharge): Cove City Wood Preserving Inc
d. Facility address: 11065 Old Hwy 70 West
Address
Cove City NC 28523
City State Zip
e. Facility contact person: Jane House [phone]
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
!f other please explain:
b. Permit issued to (company name): Culpeper of Cove City, LLC
c. Person legally responsible for permit: Josh Adkins
First MI Last
IV. Permit contact information (if different from the person legally responsible for the permit)
Revised Jan. 27, 2014
Title
11065 Old Hwy 70 West
Permit Holder Mailing Address
Cove City NC 28523
City State Zip
[phone] jadkins(&culpeperwood.com
Phone E-mail Address
d. Facility name (discharge):
Culpeper of Cove City, LLC
e. Facility address:
11065 Old Hwy 70 West
Address
Cove City NC 28523
City Stat. Zip
E Facility contact person:
Josh Adkins
First MI Last
[phone] iadkinspculpeperwood.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:
Tine
Mailing Address
Last
City State Zip
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)
V1.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):
1, Jane House, 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. ry n
1-
Signature Date
LICANT CERTIFICATION
1, Josh Adkins, attest that this application for a name/ownership change has been reviewed and is accurate
and complete to the best of my knowledge. 1 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
linined Jan. 27, 2014