NCG080583_Name-Owner Change Form_1/30/2020

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 1/30/2020 1:26:30 PM (Name Change Submission)
Approve by McCoy, Suzanne 2/3/2020 3:02:23 PM (Notification to Admin)
• The task was assigned to McCoy, Suzanne 1/30/2020 1:26 PM

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) #:
NCG080583
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: Schneider National
Conpany I brre
b. Person legally responsible for permit:
First name:* Middle name: Last name:*
Caryssa A Berg
Title:
Permit holder's mailing address:*
Phone #:*
920-
592-
3928
c. Facility name:*
d. Facility address:*
Fax #:
Street Address
3101 Packerland Drive
Address Line 2
Oty
Green Bay
Fbstal / Zip Code
54313-6187
State / Rovince / Fbgion
WI
Country
us
Schneider National Carriers - SO43
Street Address
2420 Starita Road
Address Line 2
Cty
Charlotte
Fbstal / Zip Code
28269-4429
e. Facility contact person (prior to change, optional):
First name: Middle name: Last name:
Clifford Gore
Phone #: [phone]
State / Rovince / Fegion
NC
Country
us

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:* Schneider National
Company femme
c. Person to be legally responsible for permit:
First name:* Middle name: Last name:*
Derek Townsen
d
Title: Environmental Administrator
Permit holder's mailing address:* Street Address
3101 Packerland Drive
Address Line 2
city
State / Province / Region
Green Bay
wl
Fbstal / Zip Code
Country
54313-6187
us
Phone #:* Email address:*
920- townsend
592- d@schne
3928 ider.com
d. Faciltiy name:* Schneider National Carriers - SO43
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:*
Gary Lord
Phone #:* 704-496-3523
Email address:* [e-mail]

IV. Permit Contact Information
Is the PERMIT contact different than the person legally responsible
above?*
r Yes
l: 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
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
Fixrrit-holder prior to the ownership change, or perrrit-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.lucas(c)ncdenr.gov.

Initial Review
Project ID:* Pleviewer may revise permt nurrber here if incorrect.
NCGO80583