NCGNE0282_Name-Owner Change Form_10/17/2018

Environmental
Quakry
I. Permit Information
I. Please enter the permit number for which the change is requested.
NPDES Stormwater Individual Permit #:
NC
SX
XX
XX
X
-OR-
General Permit Certificate of Coverage (COC) #:
NCGNE0282
Use this link to check the permit contact information that is currently in our database.

II. Permit Status
11. Permit status prior to requested change.
a. Permit issued to: Tyco Electronics
Conpany tarre
b. Person legally responsible for permit:
First name:* Middle name: Last name:*
Benny Yarboro
Title: Plant Manager
Permit holder's mailing address:*
Phone #:*
717-
986-
7916
c. Facility name:*
d. Facility address:*
Fax #:
Street Address
8420 Triad Drive
Address Line 2
aty
State / Rovince / Fbgion
Greensboro
NC
Fbstal / Zip Code
Country
27409-9018
us
Tyco Electronic -Triad Drive
Street Address
8420 Triad Drive
Address Line 2
aty
State / Rovince / Fbgion
Greensboro
NC
Fbstal / Zip Code
Country
27409-9018
us
e. Facility contact person (prior to change, optional):
First name: Middle name: Last name:
Phone #:

III. Requested Change Information
111. Please provide the following for the requested change (revised permit).
a. Request for changes is a result r Change in ownership of facility
of: * r Name Change of the facility or owner
b. Permit to be issued to: Commscope Connectivity LLC
Corrpany Nacre
c. Person to be legally responsible for permit:
First name:* Middle name: Last name:*
Jeffrey Dixon
Title: Director of Operations
Permit holder's mailing address:*
Street Address
8420 Triad Drive
Address Line 2
8420 Triad Drive
aty
State / Province / Plegion
Greensboro
Address Line 2
Postal / Zip Code
Country
27409-9018
aty
State / Province / Fbgion
Greensboro
NC
Postal / Zip Code
Country
27409-9018
us
Phone #:*
Email address:*
336-
Jeffrey. Di
665-
xon@co
5920
mmscope
.com
d. Faciltiy name:*
Commscope Connectivity LLC
e. Facility address:* Street Address
8420 Triad Drive
Address Line 2
aty
State / Province / Plegion
Greensboro
NC
Postal / Zip Code
Country
27409-9018
us
Is the FACILITY contact different than the person legally responsible
above?*
r Yes
r No
f. Facility contact person:
First name:* Middle name: Last name:*
Keith Whitt
Phone #:* 336-665-6008
Email address:* [e-mail]

IV. Permit Contact Information
Is the PERMIT contact different than the person legally responsible
above?
r Yes
r No
IV. Permit contact information
(if different form the person legally responsible for the permt)
...................................................................................................................................................................................
First Name:*
Middle Last Name:*
Keith
Name: Whitt
Title:
Environmental, Health & Safety
Mailing Address:*
Street Address
8420 Triad Drive
Address Line 2
City
Greensboro
Fbstal / Zip Code
27409-9018
Phone #:* 336-665-6008
Email Address:* [e-mail]
State / Rovince / Fbgion
NC
Country
US

V. Permit Facility Activities
V. Will the permitted facility continue to conduct the SAME industrial activities conducted prior to this
ownership or name change:*
r Yes
r No

VI. Signature
In the case of an ownership change request, certifications must be signed by both the permit holder
prior to the change and the new applicant. For a name change request, the signed Permittee's
Certification is sufficient.
This completed application is required for both name change and/or ownership change requests.
Legal documentation of 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.
File Upload:* Upload supporting docurrentationfor ownership change
Transfer of Ownership Letter-
31.49KB
Commscope Corporate Law.pdf
pdt only
North Carolina General Statute 143 - 215.6 b (i) provides that:
Any person who knowingly makes any false statement, representation, or certification in any application, record, report, plan, or
other document filed or required to be maintained under this Article or a rule implementing this Article; or who knowingly makes a
false statement of a material fact in a rulemaking proceeding or contested case under this Article; or who falsifies, tampers with, or
knowingly renders inaccurate any recording or monitoring device or method required to be operated or maintained under this Article
or rules of the [Environmental Management] Commission implementing this Article shall be guilty of a Class 2 misdemeanor which
may include a fine not to exceed ten thousand dollars ($10,000).
Permittee Certification: I attest that this application for a name and/or 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, or if all required supporting information is not included, this application will be considered incomplete.
Permittee Signature
J" W POPA,
Fbrrrit-holder prior to the ownership change, or permit -holder authorizing the narre change
Applicant Certification: I attest that this application for a name and/or 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, or if all required supporting information is not included, this application will be considered incomplete.
Applicant Signature
To whom the permit is to be transferred
Will another person need to complete or sign this form before it can be submitted? No problem! Simply CLICK
the "Save as Draft" button below and send the URL link to the other party to access the form. Questions? Call The
Stormwater Program at [phone] or e-mail Annette Lucas at annette.lucaslcDncdenr.gov.

Initial Review
Project ID: * Fbviewer rray revise perrrit number here i incorrect.
NCGNE0282