NCGNE0718_COMPLETE FILE - HISTORICAL_20180124

STORMWATER DIVISION CODING SHEET
.NCG PERMITS
PERMIT NO.
NCGNE
DOC TYPE
O(HISTOR ICAL FILE
DOC DATE
YYYYMMDD

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NC®ENR
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Division of Energy, Mineral & Land Resources
Land Quality SectionlStormwater Permitting
National Pollutant Discharge Elimination System
PERMIT NAMEIOWNERSHIP CHANGE FORM
Please enter the permit number for which the change is re
NPDES Permit (or)
g s o
II. Permit status prior to requested change.
a. Permit issued to (company ttame): Tr
b. Person legally responsible for permit: Joyc
First
FOR AGENCY USE ONLY
Date Received
Year
Month
Da
Certificate of Coveracc
1 Fie
N g G N E 0 7 1 8
P Joncews
M 1 Last
Ehs Engineer, Sr.
RECEIVED
_
Title
4520 Hampton
_
n C l 8 2017
_Rd
Permit Holder Mailing Address
�11_I�ik , ..- �ALI�Y
Clemmons
NC
27012
r
�B�r&wtw m11i', ING
City
State
Zip
[phone] _ (336)
766-9064
Phone
Fax
c. Facility name (discharge):
Triumph
Actuation Systems, LLC
d. Facility address:
4520 Hampton Rd.
_
Address
Clemmons
NC
27012
City
State
Zip
e. Facility contact person:
Joyce P. Jones
(336)
766-9036
First / MI 1 Last
Phone
III. Please provide the following for the requested change (revised permit).
a. Request for change is a result of: ❑ Change in ownership of the facility
® Name change of the facility or owner
If other please explain:
b. Permit issued to (company name):
c. Person legally responsible for pen -nit
d. Facility name (discharge):
e. Facility address:
f. Facility contact person:
Triumph Fluid Power and Actuation
- _
Joyce
_
Jones
First
_P
MI Last
Ehs Engineer, Sr. V/
Title
4520 Hampton Rd.
Pennit
Holder Mailing Address
Clemmons
NC 27012
City
State Zip
1336) 766-9036
_ipjones cr triumphgroup.com
Phone
_
E-mail Address
Triumph
Fluid Power and Actuation
4520 Hampton Rd
Address � V
Clemmons
NC 27012
City
State Zip
Joyce
P Jones
First
MI Last
[phone]
�pjones a triumphgroup.com
Phone
E-mail Address
Revised Jan. 27, 2014

NPDES PERMIT NAME/OWNERSHIP CHANGE FORM
Page 2 of 2
IV. Permit contact information (if different from the person legally responsible for the permit)
Permit contact:
First M I Last
Title
Mailing Address
City State zip
Phone E-mail Address
Will the permitted facility continue to conduct the same industrial activities conducted prior
V. to this ownership or name change?
® Yes f
❑ No (please explain)
VI. Required Items: TIIIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS
ARE INCOMPLETE OR MISSING:
❑ This completed application is required for both name change and/or ownership change
requests.
❑ Legal documentation of the 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.
The certifications below must be completed and signed by both the permit holder prior to the change, and
the new applicant in the case of an ownership change request. For a name change request, the signed
Applicant's Certification is sufficient.
PERMITTEE CERTIFICATION (Permit holder prior to ownership change):
I, Joyce P. Jones, attest that this application for a name/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 and that if all required supporting infotnlation is not included, this application package will be
returned as incomplete.
Signature Date
APPLICANT CERTIFICATION
1, Joyce P. Jones, attest that this application for a name/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 and that if all required supporting information is not included, this application package will be
returned as incomplete.
Signature Date
PLEASE SEND THE COMPLETE APPLICATION PACKAGE TO:
Division of =Energy, Mineral and Land Resources
Stormwater Permitting Program
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
Revised Jan. 27, 2014