NCG100188_Name-Owner Change Form_20211005

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 10/5/2021 12:28:30 PM (Name Change Submission)
Approve by McCoy, Suzanne 10/15/2021 12:54:47 PM (Notification to Admin)
• The task was assigned to McCoy, Suzanne 10/5/2021 12:28 PM

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1
NORTH CAROLINA
Enrlmnmrnfat 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
-OR-
General Permit Certificate of Coverage (COC) #:
NCG100000
NC
GX
XX
XX
X
Use this link to check the permit contact information that is currently in our database.

II. Permit Status
II. Permit status prior to requested change.
..............................................................................................................................................................................................
a. Permit issued to:*
Doan's Used Auto Parts
Company Name
b. Person legally responsible for permit:
First name:* Middle name
Liem
Title:
Permit holder's mailing address:*
Phone #: * Fax #:
704-
393-
7064
c. Facility name:*
Last name:*
Doan
Street Address
5416 Mt Holly Huntersville Rd
Address Line 2
City
Charlotte
Postal / Zip Code
28216
Doan's used auto parts
State / Province / Region
NC
Country
Mecklenburg
d. Facility address:* Street Address
5416 Mount Holly-Huntersville Road
Address Line 2
City State / Province / Region
Charlotte NC
Postal / Zip Code Country
28216-8679 Us
e. Facility contact person (prior to change, optional):
First name:
Phone M
Middle name: Last name:

III. Requested Change Information
III. Please provide the following for the requested change (revised permit).
...................................................................................................................................................................................................................................................................................................................................................
a. Request for changes is a result of: * Change in ownership of facility
• Name Change of the facility or owner
b. Permit to be issued to: * Trust Towing & Recovery
Company Name
c. Person to be legally responsible for permit:
First name:* Middle name: Last name:
Ian Grier
Title:
Permit holder's mailing address:*
Phone #:
98031
92968
d. Faciltiy name:*
Email address:*
trusttowin
g704@ya
hoo.com
Street Address
5416 Mt Holly Huntersville Rd
Address Line 2
City
Charlotte
Postal / Zip Code
28216
TRUST TOWING & RECOVERY
State / Province / Region
NC
Country
Mecklenburg
Is the FACILITY contact different than the person legally responsible above?*
Yes
No

IV. Permit Contact Information
Is the PERMIT contact different than the person legally responsible above?*
Yes
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:
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
Permit -holder prior to the ownership change, or permit -holder authorizing the name 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 [e-mail].

Initial Review
Project ID: *
Staff Member Email for Reminder CC
of Next Step
Reviewer: Revise permit number here if incorrect.
N CG 100188
Reviewer may revise if needed.
[e-mail]