NC0085871_Ownership Change_20130605

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• State of North Carolina1
Department of Environment 5
�Iand Natural Resources _Amp
Division of Water Quality
' �
NCDENR
Pat McCrory, Governor
John E. Skvarla Ill, Secretary v NORTH CAROLINA DEPARTMENT OF
Charles Wakild, P.E., Director ENVIRONMENT AND NATURAL RESOURCES
PERMIT NAME/OWNERSHIP CHANGE FORM
I. CURRENT PERMIT INFORMATION:
Permit Number: NC00_8_/_5_/_8_I_7_/_1_ or NCG5 / / / /
1. Permit holder's name: Flakt Products, Inc.
2. Facility Name: Flakt Products Remediation Site
II. NEW OWNER/NAME INFORMATION:
1. This request for a name change is a result of:
a. Change in ownership of property/company
X b. Name change only
c. Other (please explain):
2. New owner's name (name to be put on permit):
3. New owner's or signing official's name and title: Melody B. Christopher
(Person legally responsible for permit)
Environmental Project Manager
(Title)
4. Mailing address: 5 Waterside Crossing City: Windsor
State: CT Zip Code: 06095 Phone: [phone]
E-mail address: [e-mail]
THIS APPLICATION PACKAGE WILL NOT BE ACCEPTED BY THE DIVISION UNLESS ALL OF THE
APPLICABLE ITEMS LISTED BELOW ARE INCLUDED WITH THE SUBMITTAL.
REQUIRED ITEMS:
1. This completed application form
2. Legal documentation of the transfer of ownership (such as a property deed, articles of
incorporation, or sales agreement)
[see reverse side of this page for signature requirements]
1617 Mail Service Center,Raleigh,North Carolina 27699.1617 Telephone[phone] FAX[phone]
An Equal Opportunity Affirmative Action Employer 50%recycled/10%post-consumer paper

Applicant's Certification:
I, file/OJ g • CAY�'s�/�A�ev , attest that this application for a
name/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 and that
if all required supporting information and attachments are not included, this application
package will be returned as incomplete.
Signature: 6(.42412,104.-c, Date: G/s'l3
THE COMPLETED APPLICATION PACKAGE, INCLUDING ALL SUPPORTING
INFORMATION & MATERIALS, SHOULD BE SENT TO THE FOLLOWING ADDDRESS:
NC DENR /DWO/ Point Source Branch
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Version 2/12