NCG060404_Name-Owner Change Form_3/27/2020

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 3/27/2020 4:56:33 PM (Name Change Submission)
Approve by McCoy, Suzanne 3/30/2020 10:12:03 AM (Notification to Admin)
• The task was assigned to McCoy, Suzanne 3/27/2020 4:56 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) #:
NCG060404
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: Mahoney Environmental
Cor pany Wre
b. Person legally responsible for permit:
First name:* Middle name
John
Title:
Permit holder's mailing address:*
Phone #:*
80089
29392
c. Facility name:*
d. Facility address:*
Fax #:
Last name:*
Setchel I
Street Address
712 Essington Road
Address Line 2
oty
State / Rovince / Fbgion
Joliet
Illinois
Fbstal / Zip Code
Country
60435
United States
Mahoney Environmental
Street Address
501 Old Wilson Road
Address Line 2
oty
State / Rovince / Fbgion
Wendell
NC
Fbstal / Zip Code
Country
27591-7501
US
e. Facility contact person (prior to change, optional):
First name: Middle name: Last name:
Mitch Steelam
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:* Mahoney Environmental Solutions, LLC
Company %rre
c. Person to be legally responsible for permit:
First name:* Middle name
John
Title:
Permit holder's mailing address:*
Last name:*
Setchel I
Street Address
448 N. 3973 Road
Address Line 2
city
Mendota
Rbstal / Zip Code
61342
State / Province / Region
IL
Country
us
Phone #:* Email address:*
81553 johns@m
95633 endag.co
m
d. Faciltiy name:* Mahoney Environmental Solutions Raleigh
Is the FACILITY contact different than the person legally responsible
above?*
r Yes
r No
f. Facility contact person:
First name:
Mitch
Phone #:*
Middle name
9193654850
Email address:* [e-mail]
Last name:*
Steelman

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:*
Jessica Name: LeRoy
Title: Technical Director of Sustainable Solutions
Mailing Address:*
Phone #:* 8155395633
Street Address
448 North 3973rd Road
Address Line 2
City
Mendota
Fbstal / Zip Code
61342
Email Address:* [e-mail]
State / R'ovince / Region
IL
Country
us

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.
NCG060404