NCG050282_Name-Owner Change Form_4/29/2020

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 4/29/2020 12:04:43 PM (Name Change Submission)
Approve by McCoy, Suzanne 4/30/2020 9:10:35 AM (Notification to Admin)
• The task was assigned to McCoy, Suzanne 4/29/2020 12:04 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) #:
NCGO50282
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: Cooper Standard Automotive INC
Conpany Wre
b. Person legally responsible for permit:
First name:* Middle name
Terry
Title:
Permit holder's mailing address:*
Phone #:*
919-
735-
5394
c. Facility name:*
d. Facility address:*
Fax #:
Last name:*
Brosi
Engineering Manager
Street Address
308 Fedelon Trail
Address Line 2
oty
State / Rovince / Fbgion
Goldsboro
NC
Fbstal / Zip Code
Country
27530-9001
us
Cooper Standard Automotive INC
Street Address
280 Woodland Church Road
Address Line 2
aty
State / Rovince / Fbgion
Goldsboro
NC
Fbstal / Zip Code
Country
27530-7050
us
e. Facility contact person (prior to change, optional):
First name: Middle name: Last name:
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:* 280 Woodland Partners LLC
Company %rre
c. Person to be legally responsible for permit:
First name:* Middle name
Eli
Title:
Permit holder's mailing address:*
Last name:*
Zami
Street Address
120 Broadway
Address Line 2
Suite 2120
city
New York
Fbstal / Zip Code
10271
Phone #:* Email address:*
212- eli@basi
290- csportsw
8330 ear.com
d. Faciltiy name:* 280Woodland Partners LLC
State / Province / Region
NY
Country
us
e. Facility address:* Street Address
280 Woodland Church Road
Address Line 2
City
State / Province / Region
Goldsboro
NC
Fbstal / Zip Code
Country
27530-7050
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:*
Joan Nachman
i
Phone #:* 212-290-8330
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:*
Yes
r No
If no, please explain:* Warehouse use only

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
Recorded SWD.pdf 106.75KB
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
C dui -
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 [phone] or e-mail Annette Lucas at annette.lucas(@ncdenr.gov.

Initial Review
Project ID:* Pleviewer may revise permt nurrber here if incorrect.
NCG050282