NCG020146_Name-Owner Change Form_20211207

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 12/7/2021 4:00:34 PM (Name Change Submission)
Approve by Tran, Kieu M 3/25/2022 11:11:47 AM (Review Assigned to Admin)
* The Settle Statement is not sufficient for an ownership change, however, a notarized deed was found
at the Macon County Register of Deeds.
• Georgoulias, Bethany A reassigned the task to Tran, Kieu M 3/14/2022 4:23 PM
• Georgoulias, Bethany A reassigned the task to Georgoulias, Bethany A 3/13/2022 3:48 PM
P Second submittal with settlement statement docs included
• The task was assigned to DEMLR SW Admin 12/7/2021 4:00 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) #:
NCG020146
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:*
Sheffield Mine Inc
Company Name
b. Person legally responsible for permit:
First name:* Middle name: Last name:*
Linda Smith
Title: Owner/Secretary
Permit holder's mailing address:*
Phone #: *
828-
347-
1233
c. Facility name:*
d. Facility address:*
Fax #:
Street Address
1874 Georgia Rd
Address Line 2
City
State / Province / Region
Franklin
NC
Postal / Zip Code
Country
28734-1516
USA
Sheffield Mine Inc
Street Address
385 Sheffield Farms Rd
Address Line 2
City
State / Province / Region
Franklin
NC
Postal / Zip Code
Country
28734
USA
e. Facility contact person (prior to change, optional):
First name: Middle name: Last name:
Linda Smith
Phone M

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: * Sheffield Gem Mine LLC
Company Name
c. Person to be legally responsible for permit:
First name:* Middle name:
Last name:
Tanya
Campbell
Title:
Owner
Permit holder's mailing address:*
Street Address
460 Garden Lane
Address Line 2
City
State / Province / Region
Franklin
NC
Postal / Zip Code
Country
28734-5670
USA
Phone #: *
303-489-
9958
d. Faciltiy name:*
e. Facility address:*
Email address:*
tnya@vi
ridisdesig
nstudio.c
om
Sheffield Gem Mine
Street Address
385 Sheffield Farms Rd
Address Line 2
City
State / Province / Region
Franklin
NC
Postal / Zip Code
Country
28734-1516
USA
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.
Legal documentation of transfer of ownership (such as relevant pages of a contract deed, or a bill of sale)
is required for an ownership change request. Articles of incorporation are not sufficient for an ownership
change.
File Upload:* Upload supporting documentation for ownership change
settlement statement 1.pdf 101.73KB
settlement statement 2.pdf 66.73KB
pdf only
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
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Permit -holder prior to the ownership change, or permit -holder authorizing the name change
Applicant 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');
Applicant Signature
�� 0 ZI
To whom the permit is to be transferred
Date 3/25/2022

Initial Review
Project ID: *
Staff Member Email for Reminder CC
of Next Step
Reviewer: Revise permit number here if incorrect.
NCG020146
Reviewer may revise if needed.
[e-mail]