NCG020310_Name-Owner Change Form_20210331

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 3/31/2021 4:06:51 PM (Name Change Submission)
Approve by McCoy, Suzanne 4/15/2021 8:23:56 AM (Notification to Admin)
• The task was assigned to McCoy, Suzanne 3/31/2021 4:06 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) #:
NCG020310
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: Carolina Quarries, Inc
Conpany f brre
b. Person legally responsible for permit:
First name:* Middle name: Last name:*
Cedric Amar
Title: Chief Operating Officer
Permit holder's mailing address:*
Phone #:*
70463
66780
c. Facility name:*
d. Facility address:*
Fax #:
Street Address
805 Harris Granite Road
Address Line 2
C7ty
State / Rovince / Fbgion
Salisbury
NC
Fbstal / Zip Code
Country
28146
us
Gardenia White Quarry
Street Address
3399 Earnhardt Rd
Address Line 2
C7ty
State / Rovince / Fbgion
Rockwell
NC
Fbstal / Zip Code
Country
28138-8539
us
e. Facility contact person (prior to change, optional):
First name: Middle name: Last name:
Robbie Holshous
er
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:* Vulcan Construction Materials, LLC
Company %rre
c. Person to be legally responsible for permit:
First name:*
Middle name:
Last name:*
Sean
Hawley
Title:
Vice President & General Manager
Permit holder's mailing address:*
Street Address
4401 North Patterson Avenue
Address Line 2
city
State / Province / Region
Winston-Salem
NC
Rbstal / Zip Code
Country
27105-1638
us
Phone #:*
Email address:*
33676
hawleys
74600
@vmcma
il.com
d. Faciltiy name:*
Gardenia White Quarry
e. Facility address:*
Street Address
3399 Earnhardt Rd
Address Line 2
City
State / Province / Region
Rockwell
NC
Rbstal / Zip Code
Country
28138-8539
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:*
Butch Newby
Phone #:* 7042795567
Email address:* [e-mail]

IV. Permit Contact Information
Is the PERMIT contact different than the person legally responsible
above?*
r Yes
No
IV. Permit contact information
(if different form the person legally responsible for the permit)
First Name:* Middle Last Name:*
Tony Name: johnson
Title:
Mailing Address:* Street Address
11020 David Taylor Dr
Address Line 2
Suite 400
City State / R'ovince / Region
Charlotte North Carolina
Fbstal / Zip Code Country
28262 United States
Phone #:* 7045477076
Email Address:* [e-mail]

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
Gardenia NPDES Letter signed.pdf 20.6KB
Gardenia White Quarry Carolina Quarries
44.74KB
INC NPDES Permit - CA.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
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Pernit-holder prior to the ownership change, or pernit-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 w horn the permt is to be transferred
Will another person need to complete or sign this form before it can be submitted? IVo 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.lucasa-ncdenr.gov.

Initial Review
Project ID:* Pleviewer may revise permt nurrber here if incorrect.
NCG020310