NCGNE0970_COMPLETE FILE - HISTORICAL_20180222

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STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
NCGNE �'! 1
DOC TYPE
$HISTORICAL FILE
DOC DATE
❑ a � � � D
YYYYMMDD
0

. . V
Division of Energy, Mineral & Land Resources
Land Quality Section/Stormwater Permitting
National Pollutant Discharge Elimination System
NCDEN_ R
PERMIT NAME/OWNERSHIP CHANGE FORM
FOR AGENCY USE ONLY
Date Received
Year
Month De
1. Please enter the permit number for which the change is requested.
NPDES Permit (or) Ccrtificatc of Coverage
N I C I S 10 1 1 1 1 1 1 1 N I C I G I N I E 10 19 17 10
II. Permit status arior to requested change.
a. Permit issued to (company name): Kohler Company
b. Person legally responsible for permit: 1
Facility name (discharge):
Facility address:
c. Facility contact person:
First MI Last
Title
444 Highland Drive
Permit Holder Mailing Address
Kohler WI 53044 `
City State Zip
(920) 4574441 ( )
Phone Fax
Baker Furniture
2219 Shore Street
Address
High Point, NC 27263
City State Zip
Will L. Stange ( 828 ) 397-1255
First / MI / Last
Phone
111, 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 permit:
Kevin E.
Ward__
First MI
Last
COO
Title
1105 22nd Street SE
Permit Holder Mailing Address
Hickory NC
28602
City State
Zip
( 828 ) 624-7000 [e-mail]
Phone F,-mail Address
d. Facility name (discharge):
Baker Interiors Furniture Company
e. Facility address:
2219 Shore Street
/
Address
High Point, NC
27263
City State
Zip
f. Facility contact person:
Will L.
Stange
First M I
Last
[e-mail] ( 828 ) 397-1255
E-mail Address Phone E-mail Address
IV. Permit contact information (if different from the person legally responsible for the permit)
Revised Jan. 27, 2014

NPDES PERMIT NAMEIOWNERSHIP CHANGE FORM
Page 2 of 2
Permit contact: Will L. Stange
First Mt last
Project Safety Specialist
Title
1 Baker Way
Mailing Address
Connelly Springs, NC 28612
City State Zip
[e-mail] ( 828) 397-1255
E-mail address Phone E-mail Address
V. Will the permitted facility continue to conduct the same industrial activities conducted prior
to this ownership or name change?
® Yes
❑ No (please explain)
VI. Required Items: THIS APPLICATION VVILL 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 arc
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.
PERAVTTEE CERTIFICATION (Permit holder prior to ownership change):
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.
ignature Ilate
APPLICANT CERTIFICATION
1,_, 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 6ate
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