NCG140381_Name-Owner Change Application_20220525

NC DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF Energy, Mineral, and Land Resources
STORMWATER PROGRAM
NORTH CAROLINA
Environmental Quality
NPIDES STORMWATER PERMIT NAME OWNERSHIP CHANGE FORM
CURRENT PERMIT INFORMATION:
Permit Number: NCS—J--/--/--/— /, or NCG_LL�/ 0 J
1. Facility Name (prior to change): .tJen(l
II. NEW OWNER INAME INFORMATION;
2. This request for a name change is a result of:
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 addiVanal attachments if necessary.)
3. New owner's name (name to be put on permit as Permittee):
Ca LLL
4. New owner's or signing official's name and title: -Ja m CS L oc li ff n
(Person legally responsible for permit)
(Title)
5. Mailing address: 0 City. (TS 6 0 �r
State: Iv _ Zip Code: j I Phone:(
E-mail address: rn��a l +T[i��'e-�}� �?li
5. New facility name (if applicable): i� ec��t4, d r1Ce ( �]
7. Effective date of transfer or name change: 11
North Carolina Department of Env lronmel}tal Quality I Division of Energy, Mineral and Land Resources
512 North Sallsbury Street 1 1612 Mail Service Center I Raleigh, North Carolina 27699 I(12
919.707.9200

NPDES stormwater Permit Name/Ownership Change
Page 2 of 2
III. PERMIT AND FACILITY CONTACT INFORMATION
8. New permit contact's name and title: �Q lochtef)
r (Permit Contact)
�C
11
(Title)
9. Mailing address: +� UJCity: l
State: �C Zip Code:Phone: qI q
E-mail address: I'1'1(� ; dal ���c rn i Co h 0r � �'� �� 5�9
10. New facility contact's name and title: .J 0 ro ej t a r ��e
U-0
(Facility Contact)
11. Mailing address:
State: �V C
E-mail address
�oq,
Zip Cade: o[ 13 f ,
(Title)
City: 1 5 U(b
Phone:(
12. New billing contact's name: �L'nIS� LV G no o
{Billing ontact}
13. Mailing address: �� City: j � CTy-b
State: Zip Code: ' 1 3 Phone: �
( �) ) 1 `ice d d 5l
;gyp
E-mail address: er) 6 i -i of rea4 m ; L 4{� �� Ae . Dorn
FACILITY ACTIVITIES AND DISCHARGE INFORMATION
1. Will iindd strial activities at the facility remain the same as under the previous owner?
Yes L�` No ❑
2. Will the stormwater discharge location(s) remain the same? Yes I -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, and/or 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 Stormwater 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 outfali changes
as noted in item IV above (if appropriate)
Why is this information needed?
Regulations in 40 CFR §122.63 allow for minor 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 form need to be mailed in?
Permittees and applicants must fulfill signatory requirements in the NPDES federal
regulations in 40 CFR §122.22 (please see those regulations for guidance). Until NCDEQ's
electronic submission process meets Cross -Media Electronic Reporting (CROMERR)
requirements, this original signed (not digital signature) form must be marled to the
address below. The uploaded copy is stored as part of the permit record in the Division's
digital repository.
Applicant's Certification:
attest that the application for a name and/or ownership
change submitted 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 package will be considered
incomplete and may be returned.
Signature: Date: C�a�
THE COMPLETtLEY'APPLICATION AND ALL SUPPORTING INFORMATION SHOULD 8E SENT TO.
DEMLR 5tormwater Program
512 North Salisbury Street, 6tn Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
Last Revised 3/13/2022