NCG140320_Name-Owner Change Form_4/10/2020

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 4/10/2020 3:47:59 PM (Name Change Submission)
Approve by McCoy, Suzanne 4/14/2020 8:15:04 AM (Notification to Admin)
• The task was assigned to McCoy, Suzanne 4/10/2020 3:48 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) #:
NCG140320
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: PLT Concrete Services Incorporated
Cor pany I brre
b. Person legally responsible for permit:
First name:* Middle name: Last name:*
Rick Proctor
Title: CEO
Permit holder's mailing address:*
Phone #:*
252-
293-
0500
c. Facility name:*
d. Facility address:*
Fax #:
Street Address
3214 Turnage Road
Address Line 2
aty
Wilson
Fbstal / Zip Code
27893-7580
State / Rovince / Fbgion
NC
Country
us
PLT Concrete Services - Rocky Mount Plant
Street Address
4541 Dozier Rd
Address Line 2
Cty
Rocky Mount
Fbstal / Zip Code
27804-7837
e. Facility contact person (prior to change, optional):
First name: Middle name: Last name:
Dexter Clark
Phone #: [phone]
State / Rovince / Pegion
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:* Eagle Rock Concrete LLC
Company femme
c. Person to be legally responsible for permit:
First name:* Middle name: Last name:*
Adam Loftin
Title: CEO
Permit holder's mailing address:*
Street Address
8311 Bandford Way, Suite 007
Address Line 2
city
State / Province / Region
Raleigh
NC
Fbstal / Zip Code
Country
27615
us
Phone #:*
Email address:*
919-
adam@e
781-
aglerock
3744
concrete.
com
d. Faciltiy name:*
Eagle Rock Concrete - Rocky Mount Plant
e. Facility address:*
Street Address
4541 Dozier Road
Address Line 2
city
Rocky Mount
Fbstal / Zip Code
27804-7837
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:*
Dexter Clark
Phone #:* 252-451-9450
Email address:* [e-mail]
State / Province / Region
NC
Country
us

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.
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
ERC PLT Purchase document-
- 837.43KB
04092020152802-0001.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
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.
NCG140320