Loading...
HomeMy WebLinkAboutNCG170314_Name-Owner Change Form_20200720Action History (UTC-05:00) Eastern Time (US & Canada) Subrrit by Anonymous User 7/20/2020 11:36:29 AM (Name Change Submission) Approve by McCoy, Suzanne 7/22/2020 1:05:59 PM (Notification to Admin) • The task was assigned to McCoy, Suzanne 7/20/2020 11:36 AM 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) #: NCG170314 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: American & Efird LLC Conpany Wre b. Person legally responsible for permit: First name:* Middle name: Last name:* Jimmy Summers Title: Permit holder's mailing address:* Phone #:* 704- 951- 2576 c. Facility name:* d. Facility address:* Fax #: 70482 72618 Street Address PO Box 507 Address Line 2 City State / Rovince / Fbgion W. Holly NC Fbstal / Zip Code Country 28120 United States Dyeing & Finishing Plant # 15 Street Address 22 American Street Address Line 2 Oty State / Rovince / Fbgion Mt. Holly NC Fbstal / Zip Code Country 28120 United States e. Facility contact person (prior to change, optional): First name: Middle name: Last name: Jimmy Summers Phone #: 7049512576 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:* American & Efird LLC Company femme c. Person to be legally responsible for permit: First name:* Middle name: Last name:* Jimmy Summers Title: Permit holder's mailing address:* Street Address 121 West Trade St Address Line 2 Suite 1700 city Charlotte Rbstal / Zip Code 28202 Phone #:* Email address:* 704- Jimmy.Su 951- mmers@ 2576 elevatete Ailes.co m d. Faciltiy name:* Dyeing & Finishing Plant # 15 Is the FACILITY contact different than the person legally responsible above?* r Yes r No State / Province / Region NC Country United States 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. 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. In addition, I agree that submission of this form is a "transaction" subject to Chapter 66, Article 40 of the NC General Statutes (the "Uniform Electronic Transactions Act"); and I agree to conduct this transaction by electronic means pursuant to Chapter 66, Article 40 of the NC General Statutes (the "Uniform Electronic Transactions Act"); Permittee Signature if ,", 9 10"ffwct Perait-holder prior to the ownership change, or pernit-holder authorizing the narre change 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(a)ncdenr.gov. Initial Review Project ID:* Pleviewer may revise permt nurrber here if incorrect. NCG170314