NCG050087_Name-Owner Change Form_10/18/2018

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) #:
NCG050087
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: Rutland Plastic Technologies, Inc.
Company klarre
b. Person legally responsible for permit:
First name:* Middle name:
Last name:*
10021 Rodney Street
Dennis
Gunson
Title:
CEO
Pineville
Permit holder's mailing address:*
Street Address
Country
28134-8574
10021 Rodney Street
Address Line 2
oty
State / Rovince / Fbgion
Pineville
NC
Fbstal / Zip Code
Country
28134-8574
us
Phone #: * Fax #:
704-
553-
0046
c. Facility name:* Rutland Plastic Technologies, Inc.
d. Facility address:* Street Address
10021 Rodney Street
Address Line 2
oty
State / F rovince / Fbgion
Pineville
NC
Fbstal / Zip Code
Country
28134-8574
us
e. Facility contact person (prior to change, optional):
First name: Middle name: Last name:
Kimberly Leitch
Phone #: [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: PolyOne Corporation
Conpany Nacre
c. Person to be legally responsible for permit:
First name:* Middle name: Last name:*
Cooper Bishop
Title: Operations Director
Permit holder's mailing address:*
Street Address
10021 Rodney Street
Address Line 2
aty
Pineville
Fbstal / Zip Code
28134-8574
Phone #:*
Email address:*
704-
cooper. bi
553-
shop@p
0046
olyone.c
om
d. Faciltiy name: * Rutland Group, Inc
Is the FACILITY contact different than the person legally responsible
above?*
r Yes
f No
f. Facility contact person:
First name:*
Dave
Phone #:*
Middle name
704-553-0046
Email address:* [e-mail]
Last name:*
Booher
State / Rovince / Fbgion
NC
Country
us

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 perrrit)
......................................................................................................................................................................................................
First Name:*
Middle Last Name:*
Dave
Name: Booher
Title:
EH&S Manager
Mailing Address:*
Street Address
10021 Rodney Street
Address Line 2
aty
Pineville
F bstal / Zip Code
28134-8574
Phone #:* 704-553-0046
Email Address:* [e-mail]
State / Province / 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.
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
0
FLrrrit-holder prior to the ownership change, or permt-hdder authorizing the narre change
Will another person need to complete or sign this form before it can be submitted? Mo 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.lucas(a)ncdenr.gov.

Initial Review
Project ID: * Fbviewer may revise perrrit number here if incorrect.
NCG050087