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HomeMy WebLinkAboutNCG240004_Name-Owner Change Form_20190822Action History (UTC-05:00) Eastern Time (US & Canada) Submit by Anonymous User 8/22/2019 9:32:33 AM (Name Change Submission) Approve by McCoy, Suzanne 8/28/2019 11:59:21 AM (Notification to Admin) • The task was assigned to McCoy, Suzanne 8/22/2019 9:32 AM � ST1V{ NORTH C:Ft iO�INA ErtYfranminlQf QYQiff}� 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) #: NCG240004 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: McGill Environmental Systems of NC, Inc. Conpanytarre b. Person legally responsible for permit: First name:* Middle name: Last name:* Michael Noel Lyons Title: President Permit holder's mailing address:* Street Address P.O. Box 61 Address Line 2 aty State / Rovince / Fbgion Harrells NC Fbstal / Zip Code Country 28444 USA Phone #:* 919- 532- 2539 c. Facility name:* d. Facility address:* Fax #: Delway Facility Street Address 1100 Herring Road Address Line 2 aty State / Province / Fbgion Rose Hill NC Fbstal / Zip Code Country 28458-7618 US e. Facility contact person (prior to change, optional): First name: Middle name: Last name: Steve Cockman 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: McGill Environmental Systems of NC, Inc Corrpany Nacre c. Person to be legally responsible for permit: First name:* Middle name: Last name:* Michael Noel Lyons Title: President Permit holder's mailing address:* Street Address P. O. Box 61 Address Line 2 Oty State / Rovince / Fbgion Harrells NC F bstal / Zip Code Country 28444 USA Phone #:* Email address:* 919- nlyons@ 532- mcgillco 2539 mpost.co m d. Faciltiy name:* Delway Facility Is the FACILITY contact different than the person legally responsible above?* r Yes f No f. Facility contact person: First name:* Misti Phone #:* Middle name: 919-770-4416 Last name:* Benchab bat Email address:* mbenchabbat@mcgillcompost.com 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:* Misti Name: Benchab bat Title: Compliance Manager Mailing Address:* Street Address 634 Christian Chapel Church Road Address Line 2 aty State / Rovince / Fbgion New Hill North Carolina Fbstal / Zip Code Country 27562 United States Phone #:* 9197704416 Email Address:* mbenchabbat@mcgillcompost.com 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 N6 PwA46t Fbrrrit-holder prior to the ownership change, or permt-holder authorizing the narre change 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 (919) 707-3639 or e-mail Annette Lucas at annette.lucaslcDncdenr.gov. Initial Review Project ID: * Fbviewer may revise perrrit number here if incorrect. NCG240004