NCGNE0256_Name-Owner Change Application_20220721

NC DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION 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_/�_/_/_ /_ or NCG___q/j�l�� 5 /
1. Facility Name (prior to change): M S? M . P"/v 5 7 / o ' �,
II. NEW OWNER/NAME 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 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: AA or 4' C.v s
(Person legally responsible for permit)
5;Tie L-eL4/e�
(Title)
5. Mailing address: 1 165 -S ✓ M , I) City: A �
State: IV C- Zip Code: 2 '6' 7 15 Phone:( 10 y) `? 13 v S 3 � 7
E-mail address:.M r i N Ck., I 1 1 G( t T 4�_`l T- , C 0--7
6. New facility name (if applicable): 74- .e(7 -/ Tom.✓✓5 7(, z5 /rS�l �ry► � ` � C
7. Effective date of transfer or name change: J 3 ® Z Z
tt North Carolina Department of Environmental Quality I Division of Energy, Mineral and Land Resources
�1 5I2 North Salisbury Street 1 1612 Mali Service Center I Raleigh, North Carolina 27699-1612
919107.9200

NPDES Stormwater Permit Name/Ownership Change
Page 2of2
III. PERMIT AND FACILITY CONTACT INFORMATION
8. New permit contact's name and title: �� (.",7 A , n � G9v,
(Permit Contact)
(Title)
9. Mailing address:
i! Z 6 5
5%,) / Mill
A / City: C `1 � ✓1 t
State: IV L
Zip Code:
Z 6/ 7
Phone: ( �Z 1�) (2 0 - / 01 7
E-mail address:
-r\ I,?.-, c
A r,7 S L o v,
/V 4 v ii- rl 7 -r/, C o w
10. New facility contact's name and title: -r\ 1 n , A ` ) 5 W v
(Facility Contac
'r(- -s /V�`n.19</"
(Title)
11. Mailing address: l L G' 5 51 n ✓ I-4111 Rol City: C,,,/1 t l
State: IV 6
Zip Code:
2 `6 7 (
Phone:( 6 Z O -
lot 7
E-mail address:
i(,
.+ S co ,-
9 t ✓ �� �°�" ,
�p "'�
12. New billing contact's name: Pt "'% `' 4t Vf t -7
(Billing Contact)
13. Mailing address: J_7 6 5 S1 ✓ �" (� I I City:
C," v/1 Y/
State:.(V L Zip Code: % % 1 S Phone: ( �? Y) it 2-
E-mail address: Pw .n a !^ a V ten V CI l`r ir—el'r 'r / P L 0 '"'►
IV. FACILITY ACTIVITIES AND DISCHARGE INFORMATION
1. Will industrial activities at the facility remain the same asunder the previous owner?
Yes jN- No ❑
2. Will the stormwater discharge location(s) remain the same? Yes 19• 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 outfall 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 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.
1, 1An /'li n 5 Gov , 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:-7 L — 2-
THE COMPLETED APPLICATION AND ALL SUPPORTING INFORMATION SHOULD BE SENT TO:
DEMLR Stormwater Program
512 North Salisbury Street, 6t" Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
Last Revised 3/13/2022

Page 1 of 1
Type: CONSOLIDATED REAL PROPERTY
Recorded: 4/12/2022 8:23:43 AM
Fee Amt: $26.00 Page 1 of 1
Buncombe County, NC
Drew Reisinger Register of Deeds
BK 6206 PG 1797
North Carolina Department of The Secretary of State
CERTIFICATE OF NAME CHANGE
I, ELAINE F. MARSHALL, Secretary of State of the State of North
Carolina, do hereby certify that on the 21st day of March, 2022, an Articles of
Amendment Business Corporation duly executed by the proper officer to change
the corporate name of the business corporation named below with an effective date
of 3/21/2022, were filed in this office:
Name at time of submission of Articles of Amendment:
JACOB HOLM INDUSTRIES (AMERICA), INC.
Name Chanted To
GLATFELTER INDUSTRIES ASHEVILLE, INC.
I FURTHER CERTIFY that this certificate is in compliance with North
Carolina General Statutes 55D-26 and may be recorded in the office of the
Register of Deeds in the same manner as deeds, the former name of the
corporation appearing in the "Grantor" index and the amended name of the
corporation appearing in the "Grantee" index.
IN WITNESS WHEREOF, I have hereunto
0 -
set my hand and affixed my official seal at
the City of Raleigh, this 11th day of April,
2022.j�
Scan to verify online.
Certification# 113019890-1 Reference# 18515398-ds Page: 1 of 1
Verify this certificate online at https://www.sosno.gov/verification
Secretary of State
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Book: 6206 Page: 1797 Page 1 of 1