NCG100008_Name-Owner Change Form_20221005

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NC DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF Energy, Mineral, and Land Resources
RECEIVED
STORMWATER PROGRAM
NORTH CAROLINA
Environmental Quality
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)WNERSHIP CHANGE FORM
CURRENT PERMIT INFORMATION:
Permit Number: NCS����_/_ or NCG I
1. Facility Name (prior to change): Lewisville Motor Company Inc
NEW OWNER/NAME INFORMATION:
2. This request for a name change is a result of:
X 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):
Aesop Auto Parts, LLC
4. New owner's or signing official's name and title: Aimee Studna
(Person legally responsible for permit)
Signature Authority
(Title)
5. Mailing address: 5600 Country Club Rd City: Winston-Salem
State: NC Zip Code: 27104 Phone: ( 336) 765-2362
E-mail address: aimee.studnaPaesopauto.com
6. New facility name (if applicable): Aesop of North Carolina (DBA Lewisville Motor Company)
7. Effective date of transfer or name change: June 1st. 2022
North Carolina Department of Environmental Quality I Division of Energy. Mineral and Land Resources
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512 North Salisbury Street 1 1612 Mail Service Center I Raleigh. North Carolina 27699-1612
919.707.9200

NPDES Stormwater Permit Name/Ownership Change
Page 2 of 2
111. PERMIT AND FACILITY CONTACT INFORMATION
8. New permit contact's name and title: Justin Myers
(Permit Contact)
Site Manager
(Title)
9. Mailing address: 5600 Country Club Rd City: Winston-Salem
State: N_ Zip Code: 27104 Phone: ( 980 ) 247-3200
E-mail address: [e-mail]
10. New facility contact's name and title: Same as permit contact's info.
(Facility Contact)
11. Mailing address:
State:
E-mail address:
(Title)
City:
Zip Code: Phone: ( }
12. New billing contact's name: Same as permit contact's info.
(Billing Contact)
13. Mailing address:
State:
E-mail address:
Zip Code:
City:
Phone:( )
IV. FACILITY ACTIVITIES AND DISCHARGE INFORMATION
1. Will industrial activities at the facility remain the same as under the previous owner?
Yes® No
2. Will the stormwater discharge location(s) remain the same? Yes 0 No 0
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.
DEQ's
... Division's
Applicant's Certification:
f �L-I, I>n'i k- r10-, ,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: Vf2z
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THE COMPLETED APPLICATION AND ALL SUPPORTING INFORMATION SHOULD BE SENT TO:
DEMLR Stormwater Program
512 North Salisbury Street, 61h Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
Last Revised 3/13/2022