NCG060007_Name-Owner Change Form_2/12/2020

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 2/12/2020 9:54:53 AM (Name Change Submission)
Approve by McCoy, Suzanne 2/12/2020 12:16:52 PM (Notification to Admin)
• The task was assigned to McCoy, Suzanne 2/12/2020 9:54 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) #:
NCG060007
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: Keystone Foods
Cor pany I brre
b. Person legally responsible for permit:
First name:* Middle name: Last name:*
Louis G Hughes
Title: General Manager
Permit holder's mailing address:*
Phone #:*
33636
16000
c. Facility name:*
d. Facility address:*
Fax #:
Street Address
227 Equity Drive
Address Line 2
city
State / Rovince / Fbgion
Reidsville
NC
Fbstal / Zip Code
Country
27320
Rockingham
Dorada Foods
Street Address
227 Equity Drive
Address Line 2
city
State / Rovince / Fbgion
Reidsville
NC
Fbstal / Zip Code
Country
27320
Rockingham
e. Facility contact person (prior to change, optional):
First name: Middle name: Last name:
Louis G Hughes
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:* Dorada Foods
Company femme
c. Person to be legally responsible for permit:
First name:*
Middle name:
Last name:*
Louis
G
Hughes
Title:
Permit holder's mailing address:*
Street Address
227 Equity Drive
Address Line 2
CKY
State / Province / Region
Reidsville
NC
Rbstal / Zip Code
Country
27320-7000
us
Phone #:*
Email address:*
33636
louis.hug
16000
hes@dor
adafoods
.com
d. Faciltiyname:*
Dorada Foods
e. Facility address:* Street Address
227 Equity Drive
Address Line 2
Oty
State / Province / Region
Reidsville
NC
Postal / Zip Code
Country
27320-7000
us
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:*
Tina L Williams
Phone #:* 3363616027
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:*
Tina Name: Williams
L
Title: Safety and Environmental Manager
Mailing Address:* Street Address
227 Equity Drive
Address Line 2
City
State / R'ovince / Region
Reidsville
NC
Fbstal / Zip Code
Country
27320
Rockingham
Phone #:* 3363616027
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
DeOro Foods -Name Change
189.37KB
Application.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
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 wi11 be considered incomplete.
Applicant Signature
Ad_Gl ` lii,, f;Av
To w hom the permit 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.
NCG060007