NCG120056_Name-Owner Change Form_20210529

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 5/29/2021 1:43:47 PM (Name Change Submission)
Approve by McCoy, Suzanne 6/4/2021 12:57:53 PM (Notification to Admin)
• The task was assigned to McCoy, Suzanne 5/29/2021 1:44 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) #:
NCG120056
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: Republic Services of North Carolina, LLC
Cor pany f brre
b. Person legally responsible for permit:
First name:* Middle name: Last name:*
Wade Bailey
Title: General Manager
Permit holder's mailing address:*
Phone #:*
804-
482-
8337
c. Facility name:*
d. Facility address:*
Fax #:
Street Address
2001 Charles City Road
Address Line 2
oty
State / Rovince / Fbgion
Richmond
VA
Fbstal / Zip Code
Country
23231-4205
us
[e-mail]
Street Address
9650 Oxford Road
Address Line 2
aty
State / Rovince / Fbgion
Rougemont
NC
Fbstal / Zip Code
Country
27572
us
e. Facility contact person (prior to change, optional):
First name: Middle name: Last name:
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:* Republic Services of North Carolina, LLC
Company femme
c. Person to be legally responsible for permit:
First name:* Middle name: Last name:*
Wade Bailey
Title: General Manager
Permit holder's mailing address:*
Street Address
2001 Charles City Road
Address Line 2
city
Richmond
Rbstal / Zip Code
23231-4205
Phone #:* Email address:*
804- wbailey@
482- republics
8337 ervices.c
om
State / Province / Region
VA
Country
US
d. Faciltiy name:* Upper Piedmont Environmental Landfill
Is the FACILITY contact different than the person legally responsible
above?*
r Yes
r No
f. Facility contact person:
First name:
Erik
Phone #:*
Middle name
478-697-0397
Last name:*
Siebold
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:*
Matt Name: Einsman
n
Title:
Mailing Address:* Street Address
5111 Chin Page Road
Address Line 2
City State / R'ovince / Region
Durham NC
Fbstal / Zip Code Country
27703 us
Phone #:* 9196722837
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.
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.
NCG120056