NCGNE0982_Name-Owner Change Form_12/4/2019

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 12/4/2019 11:42:30 AM (Name Change Submission)
Approve by McCoy, Suzanne 12/13/2019 12:49:04 PM (Notification to Admin)
• The task was assigned to McCoy, Suzanne 12/4/2019 11:42 AM

NORTH CAROLINA
EmlmnmerrW Quality
I. Permit Information
I. Please enter the permit number for which the change is requested.
NPDES Stormwater Individual Permit #:
NC
SX
XX
XX
X
WTZIE
General Permit Certificate of Coverage (COC) #:
NCGNE0982
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: Ingersoll Rand Company
Cor pany I brre
b. Person legally responsible for permit:
First name:* Middle name: Last name:*
David Ocamb
Title: Director, Environmental Programs
Permit holder's mailing address:*
Phone #:*
704-
990-
3565
c. Facility name:*
d. Facility address:*
Fax #:
Street Address
800-E Beaty Street
Address Line 2
oty
State / F rovince / Fbgion
Davidson
NC
Fbstal / Zip Code
Country
28036
US
Ingersoll Rand Company
Street Address
501 Sanford Ave
Address Line 2
C7ty
State / F rovince / Fbgion
Mocksville
NC
Fbstal / Zip Code
Country
27028
USA
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:* Ingersoll-Rand Industrial U.S., Inc.
Company %rre
c. Person to be legally responsible for permit:
First name:*
Middle name:
Last name:*
Bryan
Miller
Title:
Plant Manager
Permit holder's mailing address:*
Street Address
501 Sanford Ave
Address Line 2
City
State / Province / Region
Mocksville
NC
Rbstal / Zip Code
Country
27028
USA
Phone #:*
Email address:*
(336)
BryanM.
751-
Miller@IR
6634
CO.COM
d. Faciltiyname:*
Ingersoll-Rand Industrial U.S., Inc.
e. Facility address:* Street Address
501 Sanford Ave
Address Line 2
City
State / Province / Region
Mocksville
NC
Fbstal / Zip Code
Country
27028
USA
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:*
Kulema McKoy
Phone #:* [phone]
Email address:* [e-mail]

IV. Permit Contact Information
Is the PERMIT contact different than the person legally responsible
above?*
r Yes
No
IV. Permit contact information
(if different form the person legally responsible for the permit)
First Name:* Middle Last Name:*
Kulema Name: McKoy
Title:
Mailing Address:* Street Address
501 Sanford Ave
Address Line 2
City
State / R'ovince / Region
Mocksville
NC
Fbstal / Zip Code
Country
27028
USA
Phone #:* [phone]
Email Address:* [e-mail]

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
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 documentation for ownership change
Ingersoll-Rand Industrial US Inc -
750.29KB
Business Contribution Agreement.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
lmel�Oewhll�
Rxrrit-holder prior to the ownership change, or perrrit-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 w horn the permt 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(d)ncdenr.gov.

Initial Review
Project ID:* Pleviewer may revise permt nurrber here if incorrect.
NCGNE0982