NC0086983_Owner (Name Change)_20150527

05-12-'15 08:45 FROM- 1-855 P002/003 F-215
ATA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Resources
Pat McCrory John E Skvarla, III
Governor WATER QUALITY PERMITTING SECTION Secretary
PERMIT NAME/OWNERSHIP CHANGE REQUEST
This form is for ownership changes or name changes of NPDES wastewater permits.
• "Permittee"references the existing permit holder
• 'Applicant"references the entity applying for the ownership/name change.
I. NPDES Permit No.(for which the change is requested): N C Q 0 S(0 1 8 3 -
or
Certificate of Coverage#: N C G 5
II. Existing Permittee Information:
a. Permit issued to(company name): 6:15j„]ei I(bVa y `lr OP Edi 4)
b. Person legally responsible for permit:
Firs i Last
♦ L J
RECEIVED/DENRIDWR Title
Po Rex
MAY 2 20 i5 Permit Holder Mailing Address
e..&{ u�`�le- Abet 27379
Water Quality City State Zip
Permitting Section e•
Phone V Fax /
C. Facility name: SO v I F/R_jYJ�,II) i4 / SCA o o 1-
d.d. Facility's physical address: „
R . . * . r_
Address
P� • e. ,r
City State ip
e. Facility contact person: Jr'i\) Ai_tiorthEIT
First 7 Ml / Last Phone
Applicant Information:
a. Request for change is a result of: Change in ownership of the facility
— Nefne change of the facility or owner I
If please explain: YY1;chae1 Brock L30Mble ie. -1-kt, Ltkrgt1i- 51A verin l okri-I�
b. Permit issued to(company name): ,• . a..fe , 0/ go ,tee, s`i ,'•i ON
C. Person legally responsible for permit: smarm oroc�-
trst r - ast 0mb)e
5upeg / d& 7 , 51— .
Title
P. o - ox 16-49
Permit Holder Mailing Address
VAAkeil 011ie, A)
City State Zip
Pt/ 69V—I-1114
Page 1 of 2 Revised 7/01/2014

05-12-'15 08:45 FROM- T-855 P003/003 F-215
d. Facility name: Sp o t t p_ tPA(`f`naw 1 S C J L n •
e. Facility's physical address; 8925 /0,C MAA/�
8 6 S,JH
City State Zip
f Facility contact person: f '
First AMI Last
r 1,9 liolertiihtze Di keerc)A
Title
(.16914-44114244AV- re_ f eLL. ei.z .tom.05
Phone Ismail Address
IV Will the permitted facility continue to conduct the same commercial industrial activities conducted prior to
this ownership or name change?
ftil Yes
D No(please explain)
If applicable,the applicant shall submit a major permit modification request to DWR A major modification shall be
defined as one that increases the volume,increases the pollutant load,results in a significant relocation of the
discharge point,or results in a change in the characteristics of the waste generated.
V. Required Items: THIS APPLICATION WILL HE RETURNED UNPROCESSED IF ITEMS ARE
INCOMPLETE OR MISSING:
1. This completed application is required for both name change and/or ownership change requests.
2. Legal documentation of the transfer of ownership(such as relevant pages of a contract deed,or a bill of sale)is
rea aired for an ownership change request. Articles of incorporation are not sufficient for an ownership change.
Applicable regulations:40 CFR 122.41,40 CFR.122.61 and 15ANCAC 02H.0114
The certifications below must be completed and signed by ILA the permit holder prior to the change(Permittee),and the
new applicant in the case of an ownership change request. For a name change request,the signed Applicant's Certification
is sufficient.
PERMITTEE CERTIFICATION(Permit holder prior to ownership change):
I,Paa,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 arc not completed and that if all required
,'ding information is not included,this application package will be returned as incomplete.
i
_ . 4, s / dols
Signature Date
APP CANT CERTIFICATION
(4171
I, attest that this application for a name/ownership change has been reviewed and is accurate and complete to the I
be of y knowledge. I .s erstand that if all required parts of this application are not completed and that if all required
sup,, ',: inf.. •: '•,, i• not included, ' application package will be returned as incomplete.
JiLfIhL 1� �_ 5/C/1
r Signature�� Date
PLEASE SEND THE COMPLETE APPLICATION PACKAGE TO:
Division of Water Resources
Watcr Quality Permitting Section
1617 Mail Service Center
NPDES PERMIT NAME/OWNERSHIP CHANGE REQUEST
Page 2 of 2 Revised 7/01/2014