NCG180090_Name-Owner Change Application_20220428

NC DEPARTMENT OF ENVIRONMENTAL QUALITY
DlvisioN OF Energy, Mineral, and Land Resources
STORMWATER PROGRAM
NORTH CAROLINA
Environmental Quality
NPDES STORMWATER PERMIT NAME/OWNERSHIP CHANGE FORM
I. CURRENT PERMIT INFORMATION:
Permit Number: NCS_/_f_—J___J_ /_ or NCGfj�J� J
1. Facility Name (prior to change): kellb( Gam NorganA-on
H. NEW OWNER/NAME INFORMATION:
2. This request for a name change is a result of:
V""a. Change in ownership of property/company
b. Name change only {Facility and/or Company)
c. Other (please explain):
(for example, facility address update. include additional attachments if necessary.)
3. New owner's name (name to be put on permit as Permittee):
4. New owner's or signing official's name and title: _-Tamm
(Person legally responsible for permit)
�J I� cad �u>!rla� i2e�I��'ces
(Title)
5. Mailing address: I Oq 5103PSGIi ee,1' City: COnoyec
State: NC zip Cade: Zg 4 ( 3 Phone:(
E-mail address:'3)\)CtylE.tol+�f.t_Ntrll'Gi+� .COc"Y I
6. New facility name (lf applicable): /= UMY'G � LAY-0 t lGly-t.
7. Effective date of transfer or name change:. _-_ Leml o - ;;q -a0,�L/
EQNorth Carolina Department or Environmental Quallty 1 division of Energy, Mineral and Land Resources
512 North Salisbury Street 11612 Mail Service Center [ Raleigh. North Carolina 27699-z612
.xnn,c.nsa7ru �^
a emv�, wa+oww 919.707.9200

NPDES Stormwater Permit Name/ownership Change
Page 2of2
III. PERMIT AND FACILITY CONTACT INFORMATION
8. New permit contact's name and title: __ Wxlk 5�ar-lo�e,
(Permit Contact)
Sc e u mano e,r,..._
9. Mailing address: 109 S iwnqsof-\ S Y` cry City: cc�-)0-4ey-
State: Zip Code: M 15 Phone; (06Z$) S Z� - S b31
E-mail address: -ram
10_ New facility contact's name and title: 1 SAU e
(Facile y Contact)
Safe ana e
{Title
11. flailing address: JQq 3 &i re, City: c on oye-
State: A _ Zip Code: ZVOIS Phone: ($fig )_� Z'3 - ��69 i
E-mail address: lh.1S , Y1Oef�.....-_--
12. New billing contact's name: Wt l - T -
(13111ing ontact)
13. Mailing address: 1 Q"1 S*1 12SQy1 S- ree,+ city- ConoyeY
State: NC Zip Code: 2S (Q J Phone: ( $Z$ ) ?2$ -5-&8 �
E-mall address:
IV. FACILITY ACTIVITIES AND DISCHARGE INFORMATION
1. Will industrial activities at the facility remain the same asunder the previous owner?
Yes X No ❑
2. Will the stormwater discharge location(s) remain the same? Yes Il No
NOTE: If either of these questions is answered `No," then more information is needed to review
the request. Please attach documentation to describe and explain the changes to the facility
activities, stormwater discharges, andjor outfall location. Depending on the information
provided, the Division may require that the new owner file a new permit application.
Last Revised 3/13/2022

NPDES Storrnwater Permit Name/Ownership Change
Page 2 of 2
THIS APPLICATION PACKAGE WILL NOT BE ACCEPTED BY THE DIVISION UNLESS
ALL OF THE ITEMS LISTED BELOW ARE INCLUDED.
REQUIRED ITEMS-
1. This completed application form (with original signature)
2. Legal documentation of transfer of ownership (such as relevant pages of a deed or a bill of sale) is
required for an ownership change request. Articles of Incorporation are not sufficient for an
ownership change but can be provided for a name change.
3. Information to document facility, industrial activities, stormwater discharges, or outfall changes
as noted in item IV above (if appropriate)
Why is this information heeded?
Regulations in 44 CFR §122.63 allow for mirror modifications to NPDES permits for a change of
ownership or operational control of a facility, provided that information supports that no other change
in the permit are necessary.
Why does this forth need to be mailed in?
Permittees and applicants Dust fulfill signatory requirements in the NPDES federal
regulations in 40 CFR §122.22 (please see those regulations for guidance). Until NCDEQs
electronic submission process meets Cross -Media Electronic Reporting (CROMERR)
requirements, this original signed (not digital signature) form must be mailed to the
address below. The uploaded copy is stored as part of the permit record in the Division's
digital repository.
Applicant's Certification:
11 _Mrm VY Sl , attest that the application for a name and/or ownership
change subrditted has been reviewed and is accurate and complete to the best of my
Knowledge. 1 understand that if all required parts of this application are not completed, or if all
required supporting information is not included, this application package will be considered
incomplete and may be returned.
Signatu Date: 4, ) ,?s 20 2 Z
THE COMPLETED APPLICATION AND ALL SUPPORTING INFORMATION SHOULD BE SENTTO:
DEMLR Stormwater Program
512 forth Salisbury Street, 61h Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
Last Revisers 3/1312022

The location of the outfalls for the facility located at 410 Hogan Street, Morganton, North Carolina will
not be changing. However, Vanguard Furniture only purchased a portion of the original property. One of
the original outfalls, Outfall #1, is on the portion of the original site not owned by Vanguard Furniture.
Therefore, it is not included in the outfalls for the Vanguard Furniture Site. A map of the original Kellex
facility is attached, as well as an updated map showing the outfalls for the Vanguard Furniture facility.

Rl
7
N
� p
� a �
L
D co
O {g
Cf) r !�
3 a)
M O 4-
E
C'?
O
C3i
oo D
--U
Z )
co In
co
IF)
P4