NCS000538_Name-Owner Change Form_20210108

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 1/8/2021 5:23:40 PM (Name Change Submission)
Approve by McCoy, Suzanne 1/11/2021 12:41:19 PM (Notification to Admin)
• The task was assigned to McCoy, Suzanne 1/8/2021 5:23 PM

NORTH CAROLINA
EmlmnmerrW Quality
I. Permit Information
I. Please enter the permit number for which the change is requested.
NPDES Stormwater Individual Permit #:
NCS000538
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: ROLL -TECH MOLDING PRODUCTS LLC
Conpany I brre
b. Person legally responsible for permit:
First name:* Middle name
PATRICE
Title:
Permit holder's mailing address:*
Phone #:*
82843
14515
c. Facility name:*
d. Facility address:*
Fax #:
Last name:*
BERTRA
ND
Street Address
243 PERFORMANCE DR SE
Address Line 2
city
HICKORY
Fbstal / Zip Code
28602
State / Rovince / Fbgion
North Carolina
Country
United States
ROLL -TECH MOLDING PRODUCTS LLC
Street Address
243 PERFORMANCE DR SE
Address Line 2
Cly
HICKORY
Fbstal / Zip Code
28602
e. Facility contact person (prior to change, optional):
First name: Middle name: Last name:
TODD BLAIR
Phone #: [phone]
State / Rovince / Fbgion
North Carolina
Country
United States

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: ROLL -TECH MOLDING PRODUCTS LLC
Corrpany Narre
c. Person to be legally responsible for permit:
First name:* Middle name
TODD
Title:
Permit holder's mailing address:*
Last name:*
BLAIR
Street Address
243 PERFORMANCE DR SE
Address Line 2
City
HICKORY
Fbstal/ Zip Code
28602
State / Frovince / Pegion
North Carolina
Country
United States
Phone #:* Email address:*
82843 TBLAIR
14515 @ROLLT
ECH.NET
d. Faciltiy name:* ROLL -TECH MOLDING PRODUCTS LLC
Is the FACILITY contact different than the person legally responsible
above?*
r Yes
No

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
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 [phone] or e-mail Annette Lucas at annette.lucas(a)ncdenr.gov.

Initial Review
Project ID:* Pleviewer may revise permt nurrber here if incorrect.
NCS000538