NCG210192_Owner Affiliation Change_20231023

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" ' ? NC DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF Energy, Mineral, and Land Resources
‘70
STORMWATER PROGRAM
NORTH CAROLINA
Environmental Quality
NPDES STORMWATER PERMIT NAME/OWNERSHIP CHANGE FORM
CURRENT PERMIT INFORMATION:
Permit Number: NCS / / f / / or NCG 2 / 1 / 0 / 1 / 9 / 2
1, Facility Name(prior to change): PalletOne Mocksville
ll. 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)
X c. Other(please explain): Change in Responsible Official
(for example,facility address update. Include additional attachments if necessary.)
3. New owner's name (name to be put on permit as Permittee):
N/A
4. New owner's or signing official's name and title: Chad Dyson
(Person legally responsible for permit)
Plant Manager
(Title)
5. Mailing address: 165 Turkey Foot Road City: Mocksville
State: NC Zip Code: 27028 Phone: ( 336 )909-9028
E-mail address: cdyson(a palletone.com
6. New facility name(if applicable): N/A
7. Effective date of transfer or name change: N/A
North Carolina Department of-Environmental Quality I Division or Energy,Mineral and Land Resources
• 512 North Salisbury Street 11612 Mall Service Center I Raleigh,North Carolina 27699-1t 12
nran�f 919.707.9200

NPDES Stormwater Permit Name/Ownership Change I.
Page 2 of 2
PERMIT AND FACILITY CONTACT INFORMATION
8. New permit contact's name and title: N/A
(Permit Contact)
(Title)
9. Mailing address: City:
State: Zip Code: Phone: (
E-mail address:
10. New facility contact's name and title:
(Facility Contact)
(Title)
11. Mailing address: City:
State: Zip Code: Phone: (
E-mail address:
12. New billing contact's name:
(Billing Contact)
13. Mailing address: City:
State: Zip Code: Phone: (
E-mail address:
IV. FACILITY ACTIVITIES AND DISCHARGE INFORMATION
1, Will industrial activities at the facility remain the same as under the previous owner?
Yes 12 No
2. Will the stormwater discharge location(s) remain the same? Yes hd 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§122.53 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:
I, Chad Dyson , 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.
PLF
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Signature: t Date: /0 THE COMPLETED APPLICATION AND ALL SUPPORTING INFORMATION SHOULD BE SENT TO:
DEMLR Stormwater Program
512 North Salisbury Street, 6th Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
Last Revised 3/13/2022

s NC Department of Environmental Quality
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Division of Energy, Mineral and Land Resources
NORTH CAROLINA
Environmental Qualtly
Stormwater eReporting iraio Form
Directions are in red.
Completion of the Storm water Electronic Reporting (eReporting) Registration Form is a
required step for the Owner and, if applicable, other User Account(s) to obtain the privilege of
submitting electronic reports to DEQ and in lieu of submitting paper reports.
In addition, this form allows for Owners to designate Facility Administrator(s) and Submitter(s)
who can act on their behalf. Owner and User(s) must agree to the Electronic Signature
Agreement (ESA) Conditions contained in this form.
A. Owner Information
The Owner is the legal entity to which/whom a permit has been issued. The Owner may be an
individual or organization. Every Owner is required to have a Responsible Official who meets
the legal signature authority requirements in 40 CFR 122.22.
• For a corporation, this individual shall a president, secretary, treasurer, or vice-president in charge of
a principal business function, or another individual who performs similar functions for the corporation,
or the manager of one or more manufacturing, production, or operating facilities who is authorized to
make management decisions about the facility operation.
• For a partnership or sole proprietorship, this individual shall be a general partner or the proprietor;
respectively; or
•
® For a municipality, State, Federal, or other public agency, this individual shall be either a principal
executive officer or ranking elected official.
Owner Name: PalletOne, Inc. - Mocksville Title: Plant Manager
Responsible Official Name: Chad Dyson Phone: [phone]
Does the Responsible Official Yes No If Yes,
already have an eDMR account? User ID:
Email Address: cdyson©palletone.com
Mailing Address: 165 Turkey Foot Road
City: Mocksville State: NC Zip: 27028
•
Stormwater Electronic Reporting Registration Form
Page 1

B. Permit Information
Include all storm water permit currently held by the Owner(both Individual and General
permits). Designate any applicable users for each permit. Attach additional pages if you need
more space.
Permit No. Facility Name Facility Address Name of the User
(if applicable)
NCG210192 PalletOne, Inc.-Mocksville 165 Turkey Foot Road,Mocksville,NC Chad Dyson
•
•
•
•
•
•
Stormwater Electronic Reporting Registration Form
Page 2

C. User Account Information
Include the following information for all User(s) listed in Part B. Attach additional pages if you
need more space.
Click on one or more of the two access roles available: Facility Administrator and/or
Submitter.
• If the user enters data and submits report on behalf of the facility, then the Submitter
role should be requested. This role is automatically approved to enter and certify the
data. This person must have signatory authority for the permit.
• If the user is the person responsible for managing user information for the facility/permit,
then the Facility Administrator role should be requested. The Facility Administrator
user can be assigned by the Responsible Official or can be assigned at the time of
registration by the Storm water eDMR Administrator. Note: If this person is responsible
for submitting eDMR reports, then they must have signatory authority for the permit.
User Account information Permit Number(s) NCG210192
Request Access Role: r/ Submitter QFacility Administrator
Name: Chad Dyson Title: Plant Manager
Do you already have an eDMR [f Yes
, 336-909-9028
r
account? Yes i i No User ID Phone:
Organization: PalletOne,Inc.-Mocksville
Email Address: [e-mail]
Mailing Address: 165 Turkey Foot Road
City: Mocksville State: NC Zip: 27028
User Account Information Permit Number(s)
Request Access Role: uSubmitter Facility Administrator
Name: Title:
Do you already have an eDMR oyes No if Yes, Phone:
account? User ID i
.......................
Organization:
Email Address:
Mailing Address:
City: State: 1 Zip:
• User Account Information Permit Number(s)
Request Access Role: uSubmitter ]Facility Administrator
Name: Title:
Do you already have an eDMR If Yes,
account? ❑Yes ❑No User ID Phone:
Organization:
Email Address:
Mailing Address:
City: State: Zip:
Stormwater Electronic Reporting Registration Form
Page 3

D. Electronic Signature Agreement Conditions
To receive and accept the required electronic signature credential, consisting of a User ID and
password, issued by the North Carolina Department of Environmental Quality (NCDEQ) in order
to sign electronic documents submitted to NCDEQ's Electronic Document Systems and to
receive electronic documents from NCDEQ's systems;
The Responsible Official and other User Account(s) (if applicable) named in this form do
herby:
I. Understand that this Electronic Signature Agreement requires me to submit electronic
documents to NCDEQ's approved eDMR system under the authorized program in lieu of
paper submissions.
2. Understand that this Electronic Signature Agreement requires me to accept electronic
transmissions, in lieu of paper transmissions of all permits, permit modifications,
authorizations to construct, and any other correspondence related to reviewing and
processing permits from NCDEQ. This authorization will not become effective until NCDEQ
establishes a system for processing electronic documents; I am notified in writing from
NCDEQ that use of the electronic systems has officially been initiated; and North Carolina
rules and statutes are changed to allow the implementation of electronic submittal and
acceptance of documents.
3. Understand that this Electronic Signature Agreement requires me to submit electronic all
necessary information for processing of NPDES application including information for renewal
of existing permits, modification to existing permits, and applications for new discharge
permits. The submittals may include all necessary applications and supporting documentation
to NCDEQ's approved system for electronic submittals in lieu of paper submissions. This
authorization will not become effective until NCDEQ establishes a system for processing
electronic documents; I am notified in writing from NCDEQ that use of the electronic systems
has officially been initiated; and North Carolina rules and statutes are changed to allow the
implementation of electronic submittal and acceptance of documents.
4. Understand that this Electronic Signature Agreement requires me to accept electronic
submissions, in lieu of paper submissions, of all Notices of Deficiency, Notices of Violation,
Civil Penalty Assessments, and any other correspondence related to compliance with federal
and state water quality laws and regulations that might be sent by NCDEQ. This authorization
will not become effective until NCDEQ establishes a system for processing electronic
documents; I am notified in writing from NCDEQ that use of the electronic systems has
officially been initiated; and North Carolina rules and statutes are changed to allow the
implementation of electronic submittal and acceptance of documents.
5. Agree to protect both the electronic signature credential, consisting of my User ID and
password, and security questions and answers, from compromise and from use by anyone
except me. Specifically, I agree to maintain the secrecy of my electronic signature credential
and security questions and answers; i will not divulge or delegate my credential or security
questions and answers to any other individual; I will not store my credential or security
questions and answers in an unprotected location; and I will not allow my electronic signature
credential or security questions and answers to be written into computer scripts to achieve
automated log-in.
6. Understand and agree that I will be held as legally bound, obligated, and responsible for the
use of my electronic signature as I would be using my hand-written signature.
7. Understand that I will be informed through my registered email address whenever my User ID
or password has been modified.
Stormwater Electronic Reporting Registration Form
Page 4

8. Understand that eDMR reports the last date my User ID and password were used immediately
after successfully logging into eDMR.
9. Agree to contact the NCDEQ SW-eDMR Administrator via email at SW-eDMRt deq,nc.gov as
soon as possible, but no later than 24 hours, after suspecting or determining that my User ID
and/or password have become lost, stolen or otherwise compromised.
10. Agree that I will review the contents of all electronic submissions prior to submission.
11. Understand that I will automatically receive an email receipt at my registered email address
from the NCDEQ's SW-eDMR system for any submission that contains a valid electronic
signature, identifying the document received, the signatory, and the date and time of receipt.
12. Agree to contact the NCDEQ SW-eDMR Administrator via email at SW-eDMRAdeq.nc.gov if
do not receive an email receipt as specified above within five (5) business days for any
electronically signed submission using my credentials.
13. Agree that if I received an email notification for an activity that I do not believe that I
performed, I will notify the NCDDEQ SW-eDMR Administrator via email at SW
eDMR a( deq,nc.gov as soon as possible, but no later than 24 hours, after receipt.
14. Agree to report, within 24 hours of discovery, any evidence of discrepancy between any
electronic document I have signed and submitted and what the NCDEQ eDMR has received
from me by contacting the NCDEQ SW-eDMR Administrator via email at
[e-mail].
15. Understand that the NCDEQ eDMR's system will automatically reject any electronic document
submitted without a valid electronic signature if such signature is required.
16. Agree to contact the NCDEQ SW-eDMR Administrator via email at SW-eDMRAdeq.nc,gov
within ten working days if my duties change and I no longer need to interact with eDMR on
behalf of my organization.
17. Agree to notify the NCDEQ SW-eDMR Administrator via email at SW-eDMRAdeq.nc.gov if I
cease to represent the regulated entity specified above as signatory of that organization's
electronic submissions as soon as this change in relationship occurs.
18, Understand that the NCDEQ may contact the Organization's Responsible Official, who signs
below to authorize me as a signatory for the Owner/Organization, in order to verify my identity.
19. Agree to retain a copy of this signed agreement as long as I continue to represent the
regulated entity specified above as signatory of the Organization's electronic submissions.
20. Certify that I have the authority to enter into this Agreement on behalf of the Organization
identified above, and I am a signatory authorized to,represent that Organization, and I am able
to sign and submit reports and other information on behalf of that Organization in the capacity
required by statute and/or regulation.
Stormwater Electronic Reporting Registration Form
Page 5

E. Responsible Official Signature
This form must be completed with an original wet signature (not digital) [40 CFR 122.221
The Responsible Official, as identified in accordance with 40 CFR 122.22, is the appropriate
individual with the authority to sign and submit reports for the organization.
, , 'y, e), fij (printed name), have the authority to enter
into
this Agreement for r. /71- 6/1 . (Owner/Organization
Name).
I request the NCDEQ grant me and, if included in Part B of this form, the named User(s), an
electronic signature credential to submit and accept documents electronically on behalf of my
organization.
I acknowledge that I, and if included in Part B of this form, the named User(s), work at/for my
organization and have authority to submit and accept electronic documents and act as a
signatory for purposes of the NCDEQ's electronic document systems.
By submitting this application, I, C-h Ct) 4e (printed name),
have read, understand, and accept the terms and conditions of this Electronic Signature
Agreement. I certify under penalty of law that I have personally examined and am familiar
with the information submitted in this application and all attachments and that, based on my
inquiry of those persons immediately responsible for obtaining the information contained in
the application, I believe that the information is true, accurate and complete. I am aware that
there are significant penalties for submitting false information, including the possibility of fine
and imprisonment.
i M doA3, PLEAS
Responsible O is is Signature Title Date8
eDMR User ID
Stormwater Electronic Reporting Registration Form
Page 6

F. User Signature
Provide a separate page for every User listed in Part B.
This form must be completed with an original wet signature (not digital) [40 CFR
122.221
Users other than the Responsible Official who can submit this agreement to request to sign
reports electronically and other information and to accept electronic documents.
I, C > f ' (printed name), am authorized by the
Responsible Official named in this document, who has the authority under the applicable
standards, to enter into this agreement for
(Owner/Organization Name).
By submitting this application, I, ; (printed name),
have read, understand, and accept the terms and conditions of this Electronic Signature
Agreement. I certify under penalty of law that I have personally examined and am familiar with 1
the information submitted in this application and all attachments and that, based on my inquiry
of those persons immediately responsible for obtaining the information contained in the
application, I believe that the information is true, accurate and complete. I am aware that there
are significant penalties for submitting false information, including the possibility of fine and
imprisonment.
l m40,q 42 3 PLEA
User Signatur Title Date
eDMR User ID
Submit the completed Stormwater Electronic Reporting Registration Form in hard copy
with original signature to:
DEMLR Stormwater Program eDMR
Attn: Stormwater eDMR Administrator
1612 Mail Service Center
Raleigh, NC 27699-1612
Stormwater Electronic Reporting Registration Form
Page 7