NCG050382_Name-Owner Change Application_20240327

C DEPARTMENT OF E[ ' `
«IO€N OF Energy, - !1=r
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* •: STORK"wATEi{PROGRAM
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Environmental(uezh(
lr � ��i V! I' i I.'L f VI AI E C
Permit Number: Nit...6 / / / / / or nICGO/ 5/> /4... / 8 /Z
1. Facility Name (prior to change): f 1i�t.- 6Cr at71 J- Fc$Eac.)
IL NEW OWNER/NA E IIvIC nlvlit` ICI1,4:
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): `' a t k5S f&yi_-
(for example,facility address update. Include additional attachments if necessary.)
3. New owner's name (name to be put on permit as Permittee):
4. New owner's®r signing official's name and title: `p
(Person legally responsible for permit)
t''t 0(0 6R..-
(Title)
5. Mailing address: 2- City: k:.W l O(,d. c 3
State: Zip Code: Z 1Z1- Phone: ( 5'(0) jet-�IQ G
E-mail address: all'`''w► ..hebc wati -elde.rovk (G-trt t
6. Hew facility name (if applicable):
7. Effective date of transfer or name change: 37z7-/z
North C,ir, ),f ment of i ,t! w du y I Division of Energy,Mineral and Land Resources
Wir` , ',I>NnrrL 11 v street I lid hi-oi ss l vict CVnttu I Raleigh,North Carolina 2?699-1612

NPDES Stormwater Permit Name/Ownership Change
Page 2 of 2
PERMIT AND FACIUT"CONTACT INFOL EyAL tTT'I,�
8. New i,ct Ll1it contact's name and title: :
( evrr it Co taLL)
(Title)
/01
9. Mailingaddress: i
b t City:
State: K1( ,, Zip Code: 2'12 - Phone: ( SqO) '1e f_7fff
E-mail address: Ce4C4pi &D Clad • Gam✓'+
10. New facility contact's name and title:
radmity Con 2ct)
(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 No LI
2. Will the stormwater discharge location(s) remain the same? Yes Q 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, storm water 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

NPDESStonnvvater Permit Name/Ownership Change
Page 2uf2 �
THIS APPLICATION �OT 1`,,,-rFPVK� E%_TYE DIVISION UNLESS �
�LLb� ['�L Cl _-& L���;� ��� m�[L����.
REQUIRED ITEMS: !
/
l. This apr.L[ca:��unfonn (with original signature)
J. Le8a| dmc of transfer of ownership (such as relevant pages ofa deed oro bill of sale) is
required for an ownership change request. Articles of incorporation are not sufficient for an
ownership chonge but can be provided for a name change.
3� �mf�rnaat�cnto�cwcunaen�' �ac�;��� im�msC��aUact�c���e� sk��nnor�2er�[sch�r�es, oroa�aA� c��o�er
as mo­ec, [m item |Y above (if appropriate)
/sthf's�­,jL�rrn7L[omm���s�� '
Regu|ationsin40CFR §122.63a||ovvforminormodificatimnatoNPDESpermitsfurachan0eof
ownership or operational control of a facility, provided that information supports that no other change
in the permit are necessary. /
|
�� y does th/sfmrmNeed to b2 mailed in?
Permittees and applicants must fulfill signatory requirements in the NPIDES federal
regulations in 40 CFN §122.22 (please see those regulations for gUid@DC2). Until N[DEQ'S
electronic submission process meets Cross-Media Electronic Reporting /[ROMERR\ �
requirements, this original signed /D0t digital signature) form n0WSt be mailed to the
address below. The uploaded copy is stored as part of the permit record in the Division's
digital repository.
attest that the application for a name and/or ownership
change submitted has been reviewed and is accurate and complete tothe best ofnny
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 rnaybe returned.
5ignatu Date:
TH E C b4PLETED AP PL!CI-TU0W A,00 ALL S U P P 0 RTI0G |0FG R NlAT|OQ SH0 ULD 3E SE NIT TO:
D E N1LR St o[@nVmB8e r Pro gra0a
512 North Sai|sb,ury StreEt, 61h Floor (Office 64010
1612 &Xail Service Center
Raleigh, NIC 27699-I6I-2
Last Revised 3/13/2O22

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