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HomeMy WebLinkAboutNCG210399_Name-Owner Change Form_4/15/2020Action History (UTC-05:00) Eastern Time (US & Canada) Subrrit by Anonymous User 4/15/2020 4:27:16 PM (Name Change Submission) Approve by McCoy, Suzanne 4/17/2020 8:36:07 AM (Notification to Admin) • The task was assigned to McCoy, Suzanne 4/15/2020 4:27 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) #: NCG210399 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: Southern Shavings Conpany I brre b. Person legally responsible for permit: First name:* Middle name: Last name:* TAYLOR J DAME Title: Permit holder's mailing address:* Street Address 300 NW 16th St Address Line 2 City State / Rovince / Fbgion Fruitland Idaho Fbstal / Zip Code Country 83619 United States Phone #:* Fax #: 20890 19637 c. Facility name:* Woodgrain Millwork Dba Natures by Woodgrain d. Facility address:* Street Address 317 Jim Cline Road, Fallston NC 28042 Address Line 2 City State / Rovince / F;bgion Fallston North Carolina Fbstal / Zip Code Country 28042 United States e. Facility contact person (prior to change, optional): First name: Middle name: Last name: Rocky Hullette Phone #: 7046891515 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:* Woodgrain Millwork Dba Natures by Woodgrain Conpany fine c. Person to be legally responsible for permit: First name:* Middle name: Last name:* TAYLOR J DAME Title: Division Manager Permit holder's mailing address:* Street Address 300 NW 16th St Phone #:* 20890 19637 d. Faciltiyname:* e. Facility address:* Address Line 2 city Fruitland Postal / Zip Code 83619 Email address:* tjdame@ woodgrai n.com State / Province / Region Idaho Country United States Woodgrain Millwork Dba Natures by Woodgrain Street Address 317 Jim Cline Road Address Line 2 City Fallston Postal / Zip Code 28042 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:* Rocky Hullette Phone #:* 7046891515 Email address:* rhullette@woodgrain.com State / Province / Region NC Country Cleveland 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 Executed APA 3-6-2020.pdf 892.14KB pdf only 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 Perrrit-holder prior to the ownership change, or permit -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 will be considered incomplete. Applicant Signature To whom 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 (919) 707-3639 or e-mail Annette Lucas at annette.lucas(@ncdenr.gov. Initial Review Project ID:* Pleviewer may revise permt nurrber here if incorrect. NCG210399