NCS000541_Name-Owner Change Form_20201022

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 10/22/2020 11:26:57 AM (Name Change Submission)
Approve by McCoy, Suzanne 11/5/2020 12:00:34 PM (Notification to Admin)
• The task was assigned to McCoy, Suzanne 10/22/2020 11:27 AM

NORTH CAROLINA
EmlmnmerrW Quality
I. Permit Information
I. Please enter the permit number for which the change is requested.
NPDES Stormwater Individual Permit #:
NCS000541
NC
SX
XX
XX
X
-OR-
General Permit Certificate of Coverage (COC) #:
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 States Cooperative Inc.
Conpany I brre
b. Person legally responsible for permit:
First name:* Middle name: Last name:*
Jennifer Bunting
Title: Manager, Environmental Programs
Permit holder's mailing address:*
Phone #:*
80428
11189
c. Facility name:*
d. Facility address:*
Fax #:
Street Address
6606 West Broad Street
Address Line 2
Cty
Richmond
Fbstal / Zip Code
23230-1717
State / Rovince / Fbgion
VA
Country
us
Southern States Lumberton Fertilizer Plant
Street Address
745 Old Whiteville Road
Address Line 2
City
Lumberton
Fbstal / Zip Code
28358
e. Facility contact person (prior to change, optional):
First name: Middle name: Last name:
Chad Hodgin
Phone #: [phone]
State / Rovince / Fegion
NC
Country
us

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:* GROWMARK, Inc.
Company %rre
c. Person to be legally responsible for permit:
First name:* Middle name: Last name:*
Randall Tomic
Title: Environmental Engineer
Permit holder's mailing address:*
Street Address
1701 Towanda Avenue
Address Line 2
PO Box 2500
city
Bloomington
Fbstal / Zip Code
61702-2500
State / Province / Region
IL
Country
us
Phone #:*
Email address:*
309.5
RTOMIC
57.60
@g rowm
00
ark.com
d. Faciltiy name:*
Lumberton Fertilizer Plant
e. Facility address:*
Street Address
745 Old Whiteville Road
Address Line 2
Qty
State / Province / Region
Lumberton
NC
Fbstal / Zip Code
Country
28358
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:*
Chad Hodgin
Phone #:* 910-739-7562
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:*
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
127908381 FULLY EXECUTED Bill of
Sale Assignment and Assumption 494.38KB
Agreement (GMK GFS SSC).pdf
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.
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
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.
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");
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 [phone] or e-mail Annette Lucas at annette.lucas(@ncdenr.gov.

Initial Review
Project ID:* Pleviewer may revise permt nurrber here if incorrect.
NCS000541