NCG020670_Name-Owner Change Form_20211130

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 11/30/2021 12:41:36 PM (Name Change Submission)
Approve by Tran, Kieu M 3/21/2022 8:10:36 AM (Review Assigned to Admin)
• Georgoulias, Bethany A reassigned the task to Tran, Kieu M 3/18/2022 1:35 PM
• Georgoulias, Bethany A reassigned the task to DEMLR SW Admin 1/25/2022 5:10 PM
• Reese, Deborah W reassigned the task to Georgoulias, Bethany A 1/25/2022 9:11 AM
P Here you, go, Bethany.
• Georgoulias, Bethany A reassigned the task to Reese, Deborah W 1/24/2022 1:51 PM
• The task was assigned to DEMLR SW Admin 11/30/2021 12:41 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) #:
NCG020670
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:*
Grissett Swamp Mine, Inc.
Company Name
b. Person legally responsible for permit:
First name:* Middle name:
Last name:*
William Eugene
Fuller
Title:
President
Permit holder's mailing address:*
Street Address
542 Andrews Lake Drive (no mail box)
Address Line 2
City
State / Province / Region
Tabor City
NC
Postal / Zip Code
Country
28463-9098
us
Phone #: * Fax #:
91065
34108
c. Facility name:* Grissett Swamp Mine
d. Facility address:* Street Address
542 Andrews Lake Drive (no mail box)
Address Line 2
City State / Province / Region
TABOR CITY NC
Postal / Zip Code Country
28463 us
e. Facility contact person (prior to change, optional):
First name: Middle name: Last name:
William Eugene Fuller
Phone M 9106534108

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: * Grissett Swamp Mine, Inc.
Company Name
c. Person to be legally responsible for permit:
First name:* Middle name: Last name:
William Eugene Fuller
Title: President
Permit holder's mailing address:*
Phone #:
9106534
108
d. Faciltiy name:*
Email address:*
ful ler992
6@yahoo
.com
Street Address
10211 SWAMP FOX HWY E
Address Line 2
City
TABOR CITY
Postal / Zip Code
28463
Grissett Swamp Mine, Inc.
State / Province / Region
NC
Country
us
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
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
clG iaa [r r "q_
Permit -holder prior to the ownership change, or permit -holder authorizing the name change
Date 3/21 /2022

Initial Review
Project ID: *
Staff Member Email for Reminder CC
of Next Step
Reviewer: Revise permit number here if incorrect.
NCG020670
Reviewer may revise if needed.
[e-mail]