NCG030707_Name-Owner Change Application (Better Scan)_20230609

NC DEPARTMENT OF ENVIRONMENTAL QUALITY
Divisi©N OF Energy, Mineral, and Land Resources
STORMWATER PROGRAM
NORTH CAROLINA
;nsdronmentzal €rcl€ry
NPDES STi RMf ATER PERMIT NAME OWNERSHIP CHANGE FORM
I. CURRENT PERMIT INFORMATION:
Permit plumber: NCS___/__/_J__J____/_ or NCG. o
1. Facility Name(prior to change): VL/6e-. .
El. NEW OWNEVNAME INFORMATION:
2. This request for a name change is a result of:
a. Change in ownership of property/company
v'"b. Name charge 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):
1 &jQ1,e,
4. New owner's or signing official's name and title:_
(Person legally responsible for permit)
T=a.1 Zsr
{Title)
S. Mailing address: City: kS44LLL0
state: ,-2- ,. Zip code:. . Phone:(7,4 ) 1 -)�
E-mail address:
6. New facility name(if applicable): f�► . � � �
7. Effective date of transfer or name change: S1
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NPDE5 Stormwater Permit Name/Ownership Change
Page 2 of 2
Ill. PERMIT AND FACILITY CONTACT INFORMATION
8. New permit contact's name and title:
(Permit Contact)
( A,-_ 4
(Title)
9, flailing address: 2)r,� City:
State: Lip Code: - Phone:('74
E-mail address: C'C:n
10. New facility contact's name and title: &'n
(Facility Contact)
(Title)
11. Mailing address: 1 Q o I �� t F;, f City. �
State:-A 4 zip Code: : Phone:( 741_� )
E-mail address
12. New Filling contact's name: 1 r
(Billing Contact)
11 Mailing address, 1 eA i 1 t City:
State:.A/< Zip Code: 4 Phone:(?q
E-mail address: I
IVY FACILITY ACTIVITIES AND DISCHARGE INFORMATION
1. Will industrial activities at the facility remain the same asunder the previous owner?
Yes® No 11
2. Will the stormwater discharge location(s)remain the same? Yes M No
NOTE: if either of these questions is ansivered"No,`then more information is needed to review
the request.Please attach documentotion to describe and explain the changes to the facility
activities,stormwater discharges,andjor outfall location.Depending on the information
provided, the Division may require that the new owner fide a new permit application.
Cast Revised 3/13/2022

NPDES Stormwater Permit Name/Ownership Change
Page 2 of 2
THIS APPLICATION PACKAGE WILL NOT RE 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(sudr 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
ownershi'o cljonn,-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 abovo(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 facility,provided that information supports that no other change
in the permit are necessary.
Why ti 5 this Min need to mailed in?
Permittees ar,�d_ipplicanis must fulfill signatory requirements in the WES federal
regulahons in 40 CFR§122-22 (please see these regulations for guidance). Until CDEQ`s
electronic submission process meets Cass-Media Electronic Reporting(CROM ERR)
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, .'el ,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: S'/51/2 _
THE COMPLETED APPLICATION AND ALL SUPPORTING INFORMATION SHOULD RE SENT TO:
DEMLR Stormwater Program
51.2 North Salisbury Street, 611 Floor(Office 64€K
1612 Mail Service Center
Raleigh,PAC 27699-161.2
Cast Revised 3/13/2022