NCG180238_Name-Owner Change Form_20181219

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 12/19/2018 10:40:52 AM (Name Change Submission)
Approve by Georgoulias, Bethany 1/8/2019 1:00:48 PM (Initial Review)
* Verified Company Name on NC Secretary of State mbsite and updated BIMS on 11812019.
• The task was assigned to Georgoulias, Bethany 12/19/2018 10:40 AM

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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) #:
NCG180238
NC
GX
XX
XX
X
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: Heritage Home Group - Lenoir Upholstery Plant
Conpany W e
b. Person legally responsible for permit:
First name:* Middle name
Chris
Title:
Permit holder's mailing address:*
Phone #:*
(828)
757-
4720
c. Facility name:*
d. Facility address:*
Fax #:
Last name:*
Caraway
Street Address
830 Complex Street
Address Line 2
aty
State / Rovince / Fbgion
Lenoir
NC
Fbstal / Zip Code
Country
28645
USA
Lenoir Upholstery Plant
Street Address
830 Complex Street
Address Line 2
aty
State / Province / Fbgion
Lenoir
NC
Fbstal / Zip Code
Country
28645
USA
e. Facility contact person (prior to change, optional):
First name: Middle name: Last name:
David Stout
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: Hamilton Square LLC
Conpany Nacre
c. Person to be legally responsible for permit:
First name:* Middle name: Last name:*
Kevin Mann
Title: Senior VP of Operations
Permit holder's mailing address:*
Street Address
PO Box 759
Address Line 2
aty
State / Province / Fbgion
Taylosrville
NC
Wstal / Zip Code
Country
28681
USA
Phone #:*
Email address:*
(828)
KevinMa
632-
nn@cmfu
9786
rniture.co
m
d. Faciltiy name:*
Lenoir UP Complex
e. Facility address:*
Street Address
830 Complex Street Southwest
Address Line 2
aty
State / Province / Fbgion
Lenoir
NC
Wstal / Zip Code
Country
28645
US
Is the FACILITY contact different than the person legally responsible
above?*
r Yes
f• No

IV. Permit Contact Information
Is the PERMIT contact different than the person legally responsible
above?
f Yes
r No

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 docurrentation for ownership change
Sales Order Miller Hill Craftmaster
5.28MB
2018.pdf
pdf only
North Carolina General Statute 143 - 215.6 b (1) 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
Perrrit-holder prior to the ow nership change, or perrrit-holder authorizing the nave 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 w horn the pern it 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.lucas(a)ncdenr.gov.

Initial Review
Project ID: * Fbviewer may revise perrrit number here if incorrect.
NCG180238