NCGNE1397_Name-Owner Change Form_20211228

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 12/28/2021 1:00:12 PM (Name Change Submission)
Approve by Tran, Kieu M 6/2/2022 3:14:36 PM (Review Assigned to Admin)
• Georgoulias, Bethany A reassigned the task to Tran, Kieu M 3/18/2022 1:30 PM
• The task was assigned to DEMLR SW Admin 12/28/2021 1:00 PM

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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) #:
NCGNE1397
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:*
Nestle Waters North America
Company Name
b. Person legally responsible for permit:
First name:* Middle name: Last name:*
James Brown
Title: Customer Service Operations
Permit holder's mailing address:*
Phone #: *
713-
558-
3206
c. Facility name:*
d. Facility address:*
Fax #:
Street Address
1840 Lindbergh Street
Address Line 2
city
Charlotte
Postal / Zip Code
28208
State / Province / Region
NC
Country
us
Ready Refresh by Nestle - Greensboro
Street Address
10553 #3 Rabdkenan Rd
Address Line 2
city
Randleman
Postal / Zip Code
27317
e. Facility contact person (prior to change, optional):
First name: Middle name: Last name:
James Brown
Phone M 713-558-3206
State / Province / Region
NC
Country
us

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: * BlueTriton Brands, LLC
Company Name
c. Person to be legally responsible for permit:
First name:* Middle name: Last name:*
Haven Sions
Title: Sr. SHE Development
Permit holder's mailing address: *
Phone #: *
304-777-
9934
d. Faciltiy name:*
Email address:*
Haven.Si
ons@wat
ers.nestle
.com
Street Address
900 Long Ridge Rd
Address Line 2
Building 2
City
Stamford
Postal / Zip Code
06902
ReadyRefresh Greensboro
State / Province / Region
CT
Country
us
Is the FACILITY contact different than the person legally responsible above?*
Yes
No
f. Facility contact person:
First name:* Middle name: Last name:
Marques Greene
Phone M * 703-463-8425
Email address: * [e-mail]

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
Permit -holder prior to the ownership change, or permit -holder authorizing the name change
Date 6/2/2022

Initial Review
Project ID: *
Staff Member Email for Reminder CC
of Next Step
Reviewer: Revise permit number here if incorrect.
NCGNE1397
Reviewer may revise if needed.
[e-mail]