NCG060189_Name-Owner Change Form_20191014

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 10/14/2019 3:16:35 PM (Name Change Submission)
Approve by McCoy, Suzanne 10/31/2019 10:03:54 AM (Notification to Admin)
• The task was assigned to McCoy, Suzanne 10/14/2019 3:16 PM

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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) #:
NCG060189
NC
GC
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: Perdue Agribusiness
Company tarre
b. Person legally responsible for permit:
First name:* Middle name: Last name:*
Wayne Black
Title:
Permit holder's mailing address:*
Phone #:*
25234
84326
c. Facility name:*
d. Facility address:*
Fax #:
Street Address
PO Box 460
Address Line 2
City
State / Rovince / Fbgion
Lewiston
NC
Fbstal / Zip Code
Country
27849
us
Perdue Farms Incorporated - Cabarrus
Street Address
862 Harris St
Address Line 2
City
State / Rovince / Fbgion
Concord
North Carolina
Fbstal / Zip Code
Country
28025
us
e. Facility contact person (prior to change, optional):
First name: Middle name: Last name:
Tom Brinson
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: Perdue Foods
Conpany Nacre
c. Person to be legally responsible for permit:
First name:* Middle name: Last name:*
Neal Summers Powell
Title: Regional Environmental Manager
Permit holder's mailing address:*
Street Address
862 Harris Street Northwest
Address Line 2
Oty
Concord
F bstal / Zip Code
28025-4308
Phone #:* Email address:*
70478 neal.pow
92461 ell@perd
ue.com
d. Faciltiy name:* Perdue Foods Concord
Is the FACILITY contact different than the person legally responsible
above?*
r Yes
r No
State / Rovince / Fbgion
NC
Country
us

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.
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
01WSDAW1e1
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 [phone] or e-mail Annette Lucas at annette.lucaslcDncdenr.gov.

Initial Review
Project ID: * Pleviewer rray revise perrrit number here i incorrect.
NCG060189