NCG070070_COMPLETE FILE - HISTORICAL_20170907

STORMWATER DIVISION CODING SHEET
RESCISSIONS .
PERMIT NO.
I,V
boo
DOC TYPE
❑COMPLETE FILE -HISTORICAL
DATE OF
RESCISSION
❑ M M 01
YYYYMMDD

Energy, Mineral &
Land Resources
ENVIRONMENTAL QUALITY
Mr. David McKeown
Meridian Brick, LLC
5100 Brickyard Road
Columbia, SC 29203
Dear Mr. McKewon:
September 7, 2017
ROY COOPER
Governor
MICHAEL S. REGAN
Secretary
TRACY DAVIS
Director
-ECEI ED
SEP 19, Z01r
CENTRAL FILES
DWR SECTION
Subject: Rescission of NPDES Stormwater Permit
Certificate of Coverage Number NCG070070
Sampson County
On July 31, 2017, the Division of Energy, Mineral and Land Resources received your request to
rescind your coverage under Certificate of Coverage Number NCG070070. In accordance with
your request, Certificate of Coverage Number NCG070070 is rescinded effective immediately.
Operating a treatment facility, discharging wastewater or discharging specific types of
stormwater to waters of the State without valid coverage under an NPDES permit is against
federal and state laws and could result in fines. If something changes and your facility would
again require stormwater or wastewater discharge permit coverage, you should notify this office
immediately. We will be happy to assist you in assuring the proper permit coverage.
If the facility is in the process of being sold, you will be performing a public service if you would
inform the new or prospective owners of their potential need for NPDES permit coverage.
If you have questions about this matter, please contact us at 919-707-9200, or the Stormwater
staff in our Mooresville Regional Office [phone].
cc: Fayetteville Regional Office
Stormwater Permitting Program
Central Files
Sincerely,
for Tracy E. Davis, PE, CPM, Director
Division of Energy, Mineral and Land Resources
Nothing Compares —,-,-
State of North Carolina I Environmental Quality I Energy, Mineral and Land Resources
512 N. Salisbury Street 11612 Mail Service Center I Raleigh, North Carolina 27699-1612
919 707 9200

Aia
NCDENR
NW C__ DE'Aw .E_ pI
Euv,npww —b N-- R,y C[S
Division of Energy, Mineral & Land Resources
Land Quality Section/Stormwater Permitting Program
National Pollutant Discharge Elimination System
RESCISSION REQUEST FORM
FOR AGENCY USE ONLY
Date Received
Year
Month
Da
Please fill out and return this form if you no longer need to maintain your NPDES stormwater permit.
1) Enter the permit number to which this request applies:
Individual Permit (or) Certificate of Coverage
N I C I S I I I I I I N I C I G O 1 7 OF 0 7 0
2) Owner/Facility Information: * Final correspondence will be mailed to the address noted below
Owner/Facility Name Meridian Brick LLC - Roseboro Plant
Facility Contact David McKeown
Street Address 5100 Brickyard Road
City Columbia State Ste_ ZIP Code 29203
County Richland E-mail Address david.mckeown(cDforterrala_corn
Telephone No. 803 691-3121 Fax: [phone]
3) Reason for rescission request (This is required information. Attach separate sheet if necessary):
® Facility closed or is closing on T212612016. All industrial activities have ceased such that no discharges of
stormwater are contaminated by exposure to industrial activities or. materials.
ffl5/l�
❑ Facility sold to on I^1 . If the facility will continue operations under the new owner it
may be more appropriate to request an ownership change to reissue to permit to the new owner.
❑ Other:
4) Certification:
I, as an authorized representative, hereby request rescission of coverage under the NPDES Stormwater Permit for the
subject facility. I am familiar with the information contained in this request and to the best of my knowledge and belief
such information is true, complete and accurate.
Signature �' �`�" Date July 26, 2017
J. David McKeown Corporate Environmental Manager
Print or type name of person signing above Title
Please return this completed rescission request form to: NPDES Permit Coverage Rescission
Stormwater Permitting Program
1612 Mail Service Center
- Raleigh, North Carolina 27699-1�CEI, `CD
1612 Mail Service Center, Raleigh, North Carolina 27699-1612 JUL12017
Phone: 91M07-63001FAX: 919-W-6492
An Equal Opportunity 1 Affirmative Action Employer DENR-LAND QUALITY
STORMWATER PERMITTING

Alexander, Laura
From:
Lawyer, Mike
Sent:
Thursday, August 31, 2017 9:38 AM
To:
Alexander, Laura
Subject:
RE: NCG070070
Good morning Laura. I conducted a site visit yesterday for the subject rescission request. I have no objections to
rescission of permit coverage.
Michael Lawyer, CPSWQ
Environmental Program Consultant
Division of Energy, Mineral and Land Resources
North Carolina Department of Environmental Quality
910 433-3394 office
mike.lawyer(cDncdenr.gov
225 Green Street, Suite 714
Fayetteville, NC 28301
Nothing Compares`-,,
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties.
From: Alexander, Laura
Sent: Wednesday, August 09, 2017 11:10 AM
To: Lawyer, Mike <[e-mail]>
Subject: NCG070070
Mike,
I forgot to mention NCG070070 is FRO too.
Thanks,
Laura
From: scanner.942A.arch@ncdenr.,gov mailto:scanner.942A.arch ncdenr. ov]
Sent: Wednesday, August 09, 2017 11:05 AM
To: Alexander, Laura <[e-mail]>
Subject: Scanned page ^

Energy, Mineral &
Land Resources
ENVIRONMENTAL QUALITY
Mr. J. David McKeown
Meridian Brick, LLC
5100 Brickyard Road
Columbia, SC 29203
Dear Mr. McKeown:
July 12, 2017
ROY COOPER
Governor
MICHAEL S. REGAN
secretary
TRACY DAVIS
Director
REC73E1 V ED
JUL 13 2017
CENTRAL FILES
DWR SECTION
Subject: NPDES Stormwater Permit NCG070070
Meridian Brick, LLC
Formerly Forterra Brick, LLC
Sampson County
Division personnel received your request to revise your stormwater permit Certificate of
Coverage to accurately reflect your new company and/or facility name.
Please find enclosed the revised Certificate of Coverage. The terms and conditions contained
in the General Permit remain unchanged and in full effect. This revised Certificate of
Coverage is issued under the requirements of North Carolina General Statutes 143-215.1 and
the Memorandum of Agreement between North Carolina and the U.S. Environmental
Protection Agency.
If you have any questions or need further information, please contact the Stormwater
Permitting Program at [phone].
Sincerely,
for racy E. Davis, P.E., PM, Director
Division of Energy, Mineral and Land
Resources
cc: Fayetteville Regional Office
Stormwater Permitting Program Files
Central Files
Nothing Compares.
SState of North Carolina I Environmental Quality f Energy, Mineral and Land Resources
S12 N. Salisbury Street 1 1612 Mail Service Center I Raleigh. North Carolina 27699-1612
919 707 9200

t. . 1
STATE OF NORTH CAROLNA
DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF ENERGY, MINERAL, AND LAND RESOURCES
GENERAL PERMIT NO. NCG070000
CERTIFICATE OF COVERAGE No. NCG070070
STORMWATER DISCHARGES
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM
In compliance with the provision of North Carolina General Statute 143-215.1, other lawful
standards and regulations promulgated and adopted by the North Carolina Environmental
Management Commission, and the Federal Water Pollution Control Act, as amended,
Meridian Brick, LLC
is hereby authorized to discharge stormwater from a facility located at:
Meridian Brick LLC
NC Highway 24 and SR 1406
Roseboro
Sampson County
to receiving waters designated as Big Swamp, a class C Sw water, in the Cape Fear River Basin;
in accordance with the effluent limitations, monitoring requirements, and other conditions set
forth in Parts I, II, III, and IV of General Permit No. NCG070000 as attached.
This certificate of coverage shall become effective July 12, 2017,
This Certificate of Coverage shall remain in effect for the duration of the General Permit.
Signed this day July 12, 2017.
for Tracy E. Davis, P.E., Directoir
Division of Energy, Mineral, and Land Resources
By the Authority of the Environmental Management Commission

State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
STATE STORMWATER PERMIT NAME/OWNERSHIP CHANGE FORM
f. CURRENT PERMIT INFORMATION �C
NCG070070
1. Stormwater Manaaement Permit Number.
2. Project Name: Forterra Brick - Roseboro Plant
3. Current Permit Holder's Company Name/Organization: Forterra Brick, LLC
".
4. Signing Official's Name: J. David McKeown Tltle: Regional Environmental Ma
5. Mailing Address: 5100 Brickyard Road
City: Columbia
6. Phone: 8( 03 ) 691-3121
State: SC
Zip: 29203
Fax; 8( 03 } 786-9703
II. PROPOSED PERMITTEE / OWNER / PROJECT / ADDRESS INFORMATION
This request is for: (please check all that apply)
x❑ Name change of the owner (Please complete Items 1, 2 and 3 below)
❑ Name change of project (Please complete Item 5 below)
❑ Change in ownership of the property/company (Please complete Items 1, 2, 3, and-4 below)
❑ Mailing address / phone number change. (Please complete Item 4 below)
❑ Other (please explain):
1. Proposed permittee's company name/organization: Meridian Brick LLC,
2. Proposed permittee's signing official's name: J. David McKeown
3. Proposed permittee's title: Corporate Environmental Manager
4. Mailing Address: 5100 Brickyard Road
City: Columbia
Phone: 8( 03 . } 691-3121
5. New Project Name to be placed on permit:
State: SC Zip: 29203
Fax: ( 803 1 786-9703
Meridian Brick LLC - Roseboro Plant
Please check the appropriate box. The proposed permittee listed above is:
❑ HOA or POA (Attach documentation showing that the HOA or POA owns, controls, or has a
recorded easement for all areas that contain stormwater system features. Print name of HOA or
POA in #1 above and provide name of HOA/POA's authorized representative in #2 above)
® The property owner
❑ Lessee (Attach a copy of the lease agreement and complete Property Owner Information on
page 4)
❑ Purchaser (Attach a copy of the pending sales agreement. Final approval of this transfer will be
granted upon receipt of a copy of the recorded deed)
❑ Developer (Complete Property Owner Information on page 4)
SSW N/O Change Rev24Sept2012 Page 1 of 4

III. - REQUIRED ITEMS
A request to transfer a permit will not be approved by the Division of Water Quality (DWQ) unless all
of the applicable required items listed below are included with the submittal. Failure to provide the
listed items may result in processing delays or denial of the transfer.
1. This completed and signed form. This certification must be completed and signed by both the
current permit holder and the new applicant if this is a change of ownership.
2. Legal documentation of the property transfer to a new owner.
3. A copy of any recorded deed restrictions, covenants, or easements, if required by the permit.
4. The designer's certification (DWQ Engineer and Designer Certification Forms are available from
each DWQ Regional office), if required by the permit and if not already submitted to DWQ.
5. If the proposed permittee is a firm, partnership, association, institution, corporation, limited liability
company, or other corporate entity, provide documentation showing the authority of the named
representative to act on behalf of the proposed permittee.
6. The $40.00 processing .fee. If this is an initial transfer from the original permittee the processing
fee is not required. Subsequent ownership transfers will require the $40.00 processing fee.
1V. CURRENT PERMITTEE'S CERTIFICATION
Please check one of the following statements and fill out the certification below that statement.
Pq Check here if the current permittee is ly changing his/her/ifs name, the project name, or mailing
address, but will retain the permit. I, , the current
permittee, hereby notify the DWQ that changing my name and/or I am changing my mailing
address and/or I am changing the name of the permitted project. I further attest that this application
for a name/ownership change 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
and attachments listed above are not included, this application package will be returned as
incomplete.
❑ Check here if current permittee is transferring the property to a new owner and will not retain
ownership of the permit.
I, , the current permittee, am submitting this application
for a transfer of ownership for permit # I hereby notify DWQ of the sale or
other legal transfer of the stormwater system associated with this permit. I have provided a copy of
the most recent permit, the designer's certification -for each BMP, any recorded deed restrictions,.
covenants, or easements, the DWQ approved plans and/or approved as -built plans, the approved
operation and maintenance agreement, past maintenance records, and the most recent DWQ
stormwater inspection report to the proposed permittee named in Sections 11 and V of this form. I
further attest that thisapplication for a name/ownership change 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 and attachments listed above are not included, this application
package will be returned as incomplete. I assign all rights and obligations as permittee to the
proposed permittee named in Sections 11 and V of this form. I understand that this transfer of
ownership cannot be approved by the DWQ unless and until the facility is in compliance with the
permit.
Signature:
I
County of
Date:
a Notary Public for the State of
do hereby certify that
personally appeared before me this the
day of , 20 , and acknowledge the due execution of the
forgoing instrument. Witness my hand and official seal,
Notary Signature
(Notary Seal)
SSW N/0 Change Rev24Sept2012 Page 2 of 4

V. 'PROPOSED PERMITTEE CERTIFICATION: (This section must be completed by the
Proposed Permittee for all transfers of ownership)
I, , hereby notify the DWQ that I have acquired
through sale, lease or legal transfer, the responsibility for operating a.nd maintaining the permitted
stormwater management system, and, if applicable, constructing the permitted system.
acknowledge and attest that I have received a copy of: (check all that apply to this permit)
❑the most recent permit
the designer's certification for each PMP
❑ any recorded deed restrictions, covenants, or easements
❑ the DWQ approved plans and/or approved as -built plans
❑ the approved operation and maintenance agreement
Bpast maintenance records from the previous permittee (where required)
DWQ stormwater inspection, report showing compliance within 90 days prior to this transfer
have reviewed the permit, approved plans and other documents listed above, and I will comply with
the terms and conditions of the permit and approved plans. I acknowledge and agree that I will
operate and maintain the system pursuant to the requirements listed in the permit and in the
operation and maintenance agreement. I further attest that this application for a name/ownership
change 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 and attachments listed
above are not included, this application package will be returned as incomplete.
Signature:
Date:
I, __ , a Notary Public for the State of
County of
do hereby certify that
personally appeared before me this the
day of , 20 and acknowledge the due execution of the
forgoing instrument. Witness my hand and official seal,
(Notary Seal)
Notary Signature
Additional copies of the original permit and the approved Operation and Maintenance agreement can
be obtained from the appropriate Regional Office of the Division of Water Quality.
This completed form, including all supporting documents and processing fee (if required), should be
sent to the appropriate Regional Office of the North Carolina Department of Environment and Natural
Resources, Division of Water Quality, as shown on the attached map.
Please note that if the Proposed Permittee listed above is not the property owner, the property owner
must complete and sign page 4 of this document. Both the lessee / developer and the property
owner will appear on the permit as permittees.
SSW N/O Change Rev24Sept2012 Page 3 of 4

VI: PROPERTY OWNER CONTACT INFORMATION AND CERTIFICATION
If the Proposed Permittee listed in Sections 11 and V of this form is not the Property Owner, the
Property.Owner must provide his/her Contact Information below and sign this form: -
Printed Name:
Organization:
Title within the Organization:
Street Address:
City:
Mailing Address:
City:
Phone:
Email:
State:
(if different from street address)
State:
Fax:
Zip:
Zip:
certify that I own the property identified in this permit transfer document and have given permission
to the Proposed Permittee listed in Sections II and V to develop and/or, .lease the property. A copy
of the lease agreement or other contract, which indicates the party responsible for the construction
and/or operation and maintenance of the stormwater system, has been provided with the submittal.
As the legal property owner I acknowledge, understand, and agree by my signature below, that I will
appear as a permittee along with the lessee/developer and I will therefore share responsibility for
compliance with the DWQ Stormwater permit. As the property owner, it is my responsibility to notify
DWQ by submitting a completed Name/Ownership Change Form within 30 days -of procuring a
developer, lessee or purchaser for the property. I understand that failure to operate and maintain the
stormwater treatment facility in accordance with the permit is a violation of NC General Statute
(NCGS) 143-215.1, and may result in appropriate enforcement action including the assessment of
civil penalties of up to $25,000 per day, pursuant to NCGS 143-215.6.
Signature of the property owner
Date:
I, , a Notary Public for the State of
, County of , do hereby certify that
personally appeared before me this the
day of , 20 , and acknowledge the due execution of the
forgoing instrument. Witness my hand and official seal,
(Notary Seal)
otary Signature
SSW N/O Change Rev24Sept2012 Page 4 of 4

" 113 M ERI DIAN'"
BRICK
5100 Brickyard Road CGVVF.0
Columbia, South Carolina 29203
meridianbrick.com Ggy 10, 2617
May 1, 2017
Central Files
NC DENR
Division of Water Quality
1617 Mail Service Center
Raleigh, NC 27699 —1617
919-807-6397
ffi�'(�IIAt�I�
Re: Change from Forterra Brick, LLC and Boral Bricks Inc. to Meridian Brick LLC
To Whom It May Concern:
This package is being sent in order to change the permit holders of the below -listed stormwater permits
in North Carolina. As background, on October 28, 2016, Boral Bricks Inc. converted to a limited liability
company named Boral Bricks LLC. On April 1, 2017, Boral Bricks LLC and Forterra Brick, LLC merged into
Meridian Brick LLC, with Meridian Brick LLC being the surviving entity. Additionally, Meridian Brick LLC is
the successor in interest to both Boral Bricks LLC and Forterra Brick, LLC by operation of law.
Additionally, a letter from Paul Samples, CEO for what was Boral Bricks LLC, Forterra Brick, LLC and is
now Meridian Brick LLC, is included which grants me, J. David McKeown, signatory authority for any
required forms or documents pertaining to this name change that require signature.
This change results in the need for us to change the names on the stormwater permits formerly held by
both Boral Bricks and Forterra Brick to Meridian Brick LLC.
The affected permits are as follows:
NC SW Permit ' Former Name New Name
NCG070215 Forterra Brick, LLC Meridian Brick LLC
Monroe Plant & Mine Monroe Plant & Mine
NCG020120 Forterra Brick, LLC Meridian Brick LLC
Anson County Mine Anson County Mine
NCG020548 Forterra Brick, LLC Meridian Brick LLC
Howell Mines 1&2 Howell Mines 1&2
BE BOLD. BE BRICIIC

MERIDIAN"
BRICK
5100 Brickyard Road
Columbia, South Carolina 29203
meridianbrick.com
NCG070070 Forterra Brick, LLC
Roseboro Plant
NCG020504 Forterra Brick, LLC
Gulf Mine #3
NCG020437 Forterra Brick, LLC
Sampson Mine II
NCG070167 Boral Bricks Inc.
Salisbury Plant
NCG020242 Boral Bricks Inc.
Gold Hill Mine
NCG020241 Boral Bricks Inc.
Thomas Mine
NCG020239 Boral Bricks Inc.
Panther Creek Mine
Meridian Brick LLC
Roseboro Plant
Meridian Brick LLC
Gulf Mine #3
Meridian Brick LLC
Sampson Mine II
Meridian Brick LLC
Salisbury Plant
Meridian Brick LLC
Gold Hill Mine
Meridian Brick LLC
Thomas Mine
Meridian Brick LLC
Panther Creek Mine
Thank you for your assistance with this matter and if you require any additional information, please do
not hesitate to contact me at 803-691-3121.
Sincerely,
• 1�
J. David McKeown
BE BOLD. BE BRICK:

no FOR4ERRA MERIDIAN"'
BRICK
April 19, 2017
Re: Signatory Authority Related to Merger of Boral Bricks Inc. and Forterra Brick, LLC
into Meridian Brick LLC
To Whom It May Concern:
Boral Bricks LLC and Forterra Brick, LLC have merged into Meridian Brick LLC and Meridian
Brick LLC is the surviving entity. The FEIN for Meridian Brick is 81-4016491. Meridian Brick
LLC is the successor in interest by operation of law to Boral Bricks LLC and Forterra Brick,
LLC.
As Chief Executive Officer for what was Boral Bricks LLC, Forterra Brick, LLC and is now
Meridian Brick LLC, let it be known that, for purposes related to the name/ownership
changes needed on any regulatory form, license or permit, Mr. J. David McKeown has
signatory authority on behalf of the above entities for any required forms or documents
requiring signature.
Thank you and if you require any additional information, please do not hesitate to contact
me at [phone] or you can contact our attorney Marie L. Joseph at [phone].
Sincerely,
A. Paul Samples
CEO
W. J. David McKeown, 5100 Brickyard Road, Columbia, SC 29203

1'.
Energy, Min era I
and Land Resources
ENVIRONMENTAL OUALtTY
May 5, 2016
Mr, J. David McKeown
Forterra Brick, LLC
5100 Brickyard Road
Columbia, SC 29203
PAT MCCRORY
Gove mor
DONALD R. VAN DER VAART
NSecrelary
TRACY DAVIS
0ireclor
RECEIVE®
MAY x 1 2 W6
CENTRAL FILES
DVUR SECTION
Subject: NPDES Stormwater Permit NCG070070
Forterra Brick, LLC
l-orinerly Hanson Brick East, L L C
Sampson County
Dear Mr. McKeown:
Division personnel received your request to revise your stormwater permit Certificate of
Coverage to accurately reflect your new company and/or facility name.
Please find enclosed the revised Certificate of Coverage. The terms and conditions contained
in the General Permit remain unchanged and in full effect. This revised Certificate of
Coverage is issued under the requirements of North Carolina General Statutes 143-215.1 and
the Memorandum of Agreement between North Carolina and the U.S. Environmental
Protection Agency. y
If you have any questions or need further information, please contact the Stormwater
Permitting Program at [phone].
Sincerely,
(7
a/
for Tracy E. Davis, P.E., CPM, Director
Division of Energy, Mineral and Land
Resources
cc: Fayetteville Regional Office
Stormwater Permitting Program Files
Central -Files
State of North Carolina I En irnnmental Quality I Energy, Mineral and Land Resources
1612 Mail Service Cemer 1 512 North Salisbury Street I Raleigh, North Carolina 27699-1612
9 1. 9 707 9220 T

f�
y ,..,.
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF ENERGY, MINERAL, AND LAND RESOURCES
GENERAL PERMIT NO. NCG070000
CERTIFICATE OF COVERAGE No. NCG070070
STORM WATER - DISCHARGES
NATIONAL POLLUTANTDISCHARGE ELIMINATION SYSTEM
In compliance xvith the provision of North Carolina General Statute 143-215.1, other lawful
standards and regulations promulgated and adopted by the North Carolina Environmental
Management Commission, and the Federal Water Pollution Control Act, as amended,
Forterra Brick, LLC
is hereby authorized to discharge stormwater from a facility located at:
Forterra I3rick, LLC
NC Highway 24 and SR 1406
Roseboro
Sampson County
to receiving waters designated as Big Swamp, a class C Sw water, in the Cape Fear River Basin;
in accordance with the effluent limitations, monitoring requirements, and other conditions set
forth in Parts 1, Il, III, and IV of General Permit No. NCG070000 as attached.
This certificate of coverage shall become effective May 5, 2016.
This Certificate of Coverage shall remain in effect for the.duration of the General Permit.
Signed this day May 5, 2016.
ef '— ) P" �- '&
for Tracy E. Davis, P.E., Director
Division of Energy, Mineral, and Land Resources
By the Authority of the Environmental Management Commission
r

Y
V/
State of North Carolina
Department of Environment and Natural Resources
�� Division of Water Quality
STATE STORMWATER PER
I. CURRENT PERMIT INFORMATION
1. Stormwater Management Permit Numbe
2. Project Name: Hanson Brick - Roseboro Plant
1 NAME/OWNERSHIP CHANGE FORM
lrt�i oar Or-� ./
✓uo'gfs /off riS� i� iv��q ��"2
NCG070070
3. Current Permit Holder's Company Name/Organization
4. Signing Official's Name: J. David McKeown
5. Mailing Address: 5100 Brickyard Road
City: Columbia
6. Phone: ( 803 ) 691-3121
Hanson Brick East, LLC
Regional Environmental Manager
Title: 9 9 r1k1111-
State: SC
Zip: 29203
Fax: [phone]
II. PROPOSED PERMITTEE 1 OWNER 1 PROJECT I ADDRESS INFORMATION
This request is for: (please check all that apply)
x❑ Name change of the owner (Please complete Items 1, 2 and 3 below)
❑ Name change of project (Please complete Item 5 below)
❑ Change in ownership of the property/company (Please complete Items 1, 2, 3, and 4 below)
❑ Mailing address / phone number change. (Please complete Item 4 below)
❑ Other (please explain):
1. Proposed permittee's company name/organization: Forterra Brick, LLC
2. Proposed permittee's signing official's name: J. David McKeown
3. Proposed permittee's title: Regional Environmental Manager
4. Mailing Address: 5100 Brickyard Road
City:
Columbia
Phone: [phone]
5. New Project Name to be placed on permit:
State: 5C Zip: 29203
Fax: ( 803 � 786-9703
For -terra Brick, LLC - Roseboro Plant
Please check the appropriate box. The proposed permittee listed above is:
❑ HOA or POA (Attach documentation showing that the HOA or POA owns, controls, or has a
recorded easement for all areas that contain stormwater system features. Print name of HOA or
POA in #1 above and provide name of HOA/POA's authorized representative in #2 above)
❑x The property owner
❑ Lessee (Attach a copy of the lease agreement and complete Property Owner Information on
page 4)
❑ Purchaser (Attach a copy of the pending sales agreement. Final approval of this transfer will be
granted upon receipt of a copy of the recorded deed)
❑ Developer (Complete Property Owner Information on page 4)
SSW N/O Change Rev24Sept2012 Page 1 of 4

III. REQUIRED ITEMS
A request to transfer a permit will not be approved by the Division of Water Quality (DWQ) unless all
of the applicable required items listed below are included with the submittal. Failure to provide the
listed items may result in processing delays or denial of the transfer.
1. This completed and signed form. This certification must be completed and signed by both the
current permit holder and the new applicant if this is a change of ownership.
2. Legal documentation of the property transfer to a new owner.
3. A copy of any recorded deed restrictions, covenants, or easements, if required by the permit.
4. The designer's certification (DWQ Engineer and Designer Certification Forms are available from
each DWQ Regional office), if required by the permit and if not already submitted to DWQ.
5. If the proposed permittee is a firm, partnership, association, institution, corporation, limited liability
company, or other corporate entity, provide documentation showing the authority of the named
representative to act on behalf of the proposed permittee.
6. The $40.00 processing fee. If this is an initial transfer from the original permittee the processing
fee is not required. Subsequent ownership transfers will require the $40.00 processing fee.
IV. CURRENT PERMITTEE'S CERTIFICATION
Please check one of the following statements and fill out the certification below that statement:
® Check here if the current permittee is n. changi his/her/its name, the project name, or mailing
address, but will retain the permit. I, 'I , the current
permittee, hereby notify the DWQ that am changing my name and/or I am changing my mailing
address and/or I am changing the name of the permitted project. I further attest that this application
for a name/ownership change 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
and attachments listed above are not included, this application package will be returned as
incomplete.
❑ Check here if current permittee is transferring the property to a new owner and will not retain
ownership of the permit.
I, _ _ , the current permittee, am submitting this application
for a transfer of ownership for permit # . I hereby notify DWQ of the sale or
other legal transfer of the stormwater system associated with this permit. I have provided a copy of
the most recent permit, the designer's certification for each BMP, any recorded deed restrictions,
covenants, or easements, the DWQ approved plans and/or approved as -built plans, the approved
operation and maintenance agreement, past maintenance records, and the most recent DWQ
stormwater inspection report to the proposed permittee named in Sections II and V of this form. I
further attest that this application for a name/ownership change is accurate and complete to the best
of my knowledge. I understand that if all required parts of this application are not completed or it all
required supporting information and attachments listed above are not included, this application
package will be returned as incomplete. I assign all rights and obligations as permittee to the
proposed permittee named in Sections II and V of this form. I understand that this transfer of
ownership cannot be approved by the DWQ unless and until the facility is in compliance with the
permit.
Signature:
County of
Date:
a Notary Public for the State of
do hereby certify that
personally appeared before me this the
day of , 20 , and acknowledge the due execution of the
forgoing instrument. Witness my hand and official seal, (Notary Seal)
Notary Signature
SSW N/O Change Rev24Sept2012 Page 2 of 4

V. PROPOSED PERMITTEE CERTIFICATION: (This section must be completed by the
Proposed Permittee for all transfers of ownership)
I, , hereby notify the DWQ that I have acquired
through sale, lease or legal transfer, the responsibility for operating and maintaining the permitted
stormwater management system, and, if applicable, constructing the permitted system. I
acknowledge and attest that I have received a copy of: (check all that apply to this permit)
the most recent permit
the designer's certification for each BMP
❑ any recorded deed restrictions, covenants, or easements
❑ the DWQ approved plans and/or approved as -built plans
❑ the approved operation and maintenance agreement
8 past maintenance records from the previous permitee (where required)
DWQ stormwater inspection report showing compliance within 90 days prior to this transfer
I have reviewed the permit, approved plans and other documents listed above, and I will comply with
the terms and conditions of the permit and approved plans. I acknowledge and agree that I will
operate and maintain the system pursuant to the requirements listed in the permit and in the
operation and maintenance agreement. I further attest that this application for a name/ownership
change 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 and attachments listed
above are not included, this application package will be returned as incomplete.
Signature:
, County of
Date:
a Notary Public for the State of
do hereby certify that
personally appeared before me this the
day of , 20 , and acknowledge the due execution of the
forgoing instrument. Witness my hand and official seal,
Notary Signature
(Notary Seal)
Additional copies of the original permit and the approved Operation and Maintenance agreement can
be obtained from the appropriate Regional Office of the Division of Water Quality.
This completed form, including all supporting documents and processing fee (if required), should be
sent to the appropriate Regional Office of the North Carolina Department of Environment and Natural
Resources, Division of Water Quality, as shown on the attached map.
Please note that if the Proposed Permittee listed above is not the property owner, the property owner
must complete and sign page 4 of this document. Both the lessee / developer and the property
owner will appear on the permit as permittees.
SSW N/O Change Rev24Sept2012 Page 3 of 4

VI. PROPERTY OWNER CONTACT INFORMATION AND CERTIFICATION
If the Proposed Permittee listed in Sections 11 and V of this form is not the Property Owner, the
Property Owner must provide his/her Contact Information below and sign this form:
Printed Name:
Organization:
Title within the Organization:
Street Address:
City:
Mailing Address:
City:
Phone:
Email:
State:
(if different from street address)
State:
Fax:
Zip:
Zip:
I certify that I own the property identified in this permit transfer document and have given permission
to the Proposed Permittee listed in Sections II and V to develop and/or, lease the property. A copy
of the lease agreement or other contract, which indicates the party responsible for the construction
and/or operation and maintenance of the stormwater system, has been provided with the submittal.
As the legal property owner I acknowledge, understand, and agree by my signature below, that I will
appear as a permittee along with the lessee/developer and I will therefore share responsibility for
compliance with the DWQ Stormwater permit. As the property owner, it is my responsibility to notify
DWQ by submitting a completed Name/Ownership Change Form within 30 days of procuring a
developer, lessee or purchaser for the property. 1 understand that failure to operate and maintain the
stormwater treatment facility in accordance with the permit is a violation of NC General Statute
(NCGS) 143-215.1, and may result in appropriate enforcement action including the assessment of
civil penalties of up to $25,000 per day, pursuant to NCGS 143-215.6.
Signature of the property owner
County of
Date:
a Notary Public for the State of
do hereby certify that
personally appeared before me this the
day of , 20 , and acknowledge the due execution of the
forgoing instrument. Witness my hand and official seal,
(Notary Seal)
Notary Signature
SSW N/O Change Rev24Sept2012 Page 4 of 4