NCG030646_Name-Owner Change Form_20220228

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 2/28/2022 4:46:12 PM (Name Change Submission)
Approve by Georgoulias, Bethany A 3/15/2022 2:35:58 PM (Review Assigned to Admin)
* Revised Company and Facility names in BIMS on 3/15/2022; revised contact information.
• Georgoulias, Bethany A reassigned the task to Georgoulias, Bethany A 3/11/2022 1:53 PM
• The task was assigned to DEMLR SW Admin 2/28/2022 4:46 PM

I�
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) #:
NCG030646
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: * Deere -Hitachi Construction Machinery Corporation
"West Campus"
Company Name
b. Person legally responsible for permit:
First name:* Middle name: Last name:*
Jonathan Chase
Title: General Manager
Permit holder's mailing address: * Street Address
PO Box 1187
Address Line 2
City State / Province / Region
Kernersville NC
Postal / Zip Code Country
27285 United States
Phone M *
Fax M
336-
996-
8100
c. Facility name:*
Deere -Hitachi Deere -Hitachi Construction Machinery
Corporation "West Campus"
d. Facility address:*
Street Address
1000 Deere -Hitachi Rd
Address Line 2
City
State / Province / Region
Kernersville
NC
Postal / Zip Code
Country
27284
US
e. Facility contact person (prior to change, optional):
First name: Middle name: Last name:
Phone #:

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: * John Deere Kernersville, LLC "West Campus"
Company Name
c. Person to be legally responsible for permit:
First name:* Middle name: Last name:
Jonathan Chase
Title: General Manager
Permit holder's mailing address:*
Phone #: *
336-
996-
8100
d. Faciltiy name:*
Email address:*
chasej@
dhcmc.co
m
Street Address
1000 Deere -Hitachi Road
Address Line 2
City
Kernersville
Postal / Zip Code
27284
State / Province / Region
NC
Country
us
John Deere Kernersville, LLC "West Campus"
Is the FACILITY contact different than the person legally responsible above?*
Yes
No
f. Facility contact person:
First name:* Middle name: Last name:
Maria Rumley
Phone #: * 336-996-8100
Email address:* [e-mail]

IV. Permit Contact Information
Is the PERMIT contact different than the person legally responsible above?*
Yes
No
IV. Permit contact information
(if different form the person legally responsible for the permit)
......... ......... ......... ......... ......... ......... ......... .........
First Name:* Middle Name: Last Name:*
Debra Randlem
an
Title: Environmental Coordinator II
Mailing Address:* Street Address
1000 Deere -Hitachi Road
Address Line 2
City State / Province / Region
Kernersville NC
Postal / Zip Code Country
27284 us
Phone #: * 336-996-8100 ext 8144
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:
Yes
No

VI. Signature
This completed application is required for both name change and/or ownership change requests.
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.
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
a77«a�.ue C��iroe
Permit -holder prior to the ownership change, or permit -holder authorizing the name change
Date 3/15/2022

Initial Review
Project ID: *
Staff Member Email for Reminder CC
of Next Step
Reviewer: Revise permit number here if incorrect.
NCG030646
Reviewer may revise if needed.
[e-mail]