NCG080828_Name-Owner Change Form_20220204

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 2/4/2022 2:19:59 PM (Name Change Submission)
Approve by Georgoulias, Bethany A 3/25/2022 9:59:26 AM (Review Assigned to Admin)
* Discussed with Matt Einsmann on 3/25/2022 by phone. Republic Services LLC is set up as a group of
owner entities in BIMS, and this facility will now be associated with "Republic Services of North
Carolina LLC - Troy" (which has Billy Maness designated as the legally responsible official). Revised
facility owner in BIMS on 3/25/2022 and added other contacts.
• Georgoulias, Bethany A assigned the task to Georgoulias, Bethany A 3/21/2022 3:23 PM
• The task was assigned to DEMLR SW Admin 2/4/2022 2:20 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) #:
NCG080828
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:*
Republic Services of North Carolina LLC - Raleigh
Company Name
b. Person legally responsible for permit:
First name:* Middle name: Last name:*
Joseph Dehner
Title: General Manager
Permit holder's mailing address:*
Phone #: *
919-
868-
2195
c. Facility name:*
d. Facility address:*
Fax #:
Street Address
2477 U.S. Highway 301 North
Address Line 2
city
State / Province / Region
Dunn
NC
Postal / Zip Code
Country
28335
US
Republic Waste Services - DUnn
Street Address
2477 U.S. Highway 301 North
Address Line 2
city
State / Province / Region
Dunn
NC
Postal / Zip Code
Country
28335
US
e. Facility contact person (prior to change, optional):
First name: Middle name: Last name:
Michael Novicky
Phone M 910-477-8282

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: * Republic Services of North Carolina, LLC - Troy
Company Name
c. Person to be legally responsible for permit:
First name:* Middle name: Last name:
William Manness
Title: General Manager
Permit holder's mailing address:* Street Address
1137 Albemarle Rd
Address Line 2
City State / Province / Region
Troy NC
Postal / Zip Code Country
27371 us
Phone #: * Email address:*
910-606- wmaness
3183 @republi
cservices
.com
d. Faciltiy name:* Republic Waste Services - Dunn
Is the FACILITY contact different than the person legally responsible above?*
Yes
No
f. Facility contact person:
First name: * Middle name: Last name:*
Joseph Dehner
Phone #: * 919-868-2195
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:*
Joseph Dehner
Title: Operations Manager
Mailing Address:* Street Address
2477 U.S.301
Address Line 2
City
State / Province / Region
Dunn
NC
Postal / Zip Code
Country
28335
US
Phone #: * 919-868-2195
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
12tzlssr 0 6Q
Permit -holder prior to the ownership change, or permit -holder authorizing the name change
Date 3/25/2022

Initial Review
Project ID: *
Staff Member Email for Reminder CC
of Next Step
Reviewer: Revise permit number here if incorrect.
NCG080828
Reviewer may revise if needed.
[e-mail]