NCG030224_Name-Owner Change Form_20210125

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 1/25/2021 1:49:19 PM (Name Change Submission)
Approve by McCoy, Suzanne 1/25/2021 2:16:12 PM (Notification to Admin)
• The task was assigned to McCoy, Suzanne 1/25/2021 1:49 PM

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) #:
NCG030224
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: Johnson Controls Battery Group
Conpany I brre
b. Person legally responsible for permit:
First name:* Middle name: Last name:*
Aaron Kramer
Title: Environmental Engineer
Permit holder's mailing address:*
Phone #:*
336-
655-
4237
c. Facility name:*
d. Facility address:*
Fax #:
Street Address
2701 Johnson Controls Drive
Address Line 2
oty
State / Rovince / Fbgion
Kernersville
NC
Fbstal / Zip Code
Country
27284-5200
us
Johnson Controls Battery Group
Street Address
2701 Johnson Controls Drive
Address Line 2
aty
State / Rovince / Fbgion
Kernersville
NC
Fbstal / Zip Code
Country
27284-5200
us
e. Facility contact person (prior to change, optional):
First name: Middle name: Last name:
Aaron Kramer
Phone #: [phone]

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:* Clarios LLC
Conpany fine
c. Person to be legally responsible for permit:
First name:* Middle name: Last name:*
Aaron Kramer
Title: Environmental Engineer
Permit holder's mailing address:*
Street Address
2701 Powering Progress Drive
Address Line 2
27
city
Kernersville
Fbstal / Zip Code
27284
Phone #:* Email address:*
336- aaron.kr
655- amer@cl
4237 arios.co
m
d. Faciltiy name:* Clarios LLC
State / Province / Region
North Carolina
Country
United States
e. Facility address:* Street Address
2701 Powering Progress Drive
Address Line 2
city State / Province / Region
Kernersville North Carolina
Fbstal / Zip Code Country
27284 United States
Is the FACILITY contact different than the person legally responsible
above?*
r Yes
r 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.
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
2nd Communication Letter Legal Entity
347.6KB
Change_October 1st 2019.pdf
Clarios_LLC_Fact Sheet.pdf
298.04KB
Johnson Controls Battery Group, LLC-WI-
54.3KB
Amendment (Change of Name).pdf
WC600 Clarios LLC - Form W-8EC1-
106.14KB
EXECUTED for vendors.pdf
pdt 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.lucasCaDncdenr.gov.

Initial Review
Project ID:* Pleviewer may revise permt nurrber here if incorrect.
NCG030224