NCGNE0691_COMPLETE FILE - HISTORICAL_20100517

STORMWATER DIVISION CODING SHEET
NCG PERMITS
PERMIT NO.
DOC TYPE P' HISTORICAL FILE
❑ MONITORING REPORTS
DOC DATE ❑
YYYYMMDD

NC®ENR
North Carolina Department of Environment and Natural Resources
Division of Water QuaRy
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor Director u C
AM
cretary
May 14, 2010
Tarheel Plastics LLC MAY 1 7 2010
Attn: Mr. John E. Collins
2018 E US Highway 64 D�NR - WA R
Lexington, NC 27292 1 WeMnds a Sbrmwater Branch
Subject: No-Exposure Certification NCGNE0691
Rescission of Permit NCG050143
Tarheel Plastics Inc.
Davidson County
Dear Mr. Collins:
The Division has reviewed your application for No-Exposure Certification for Exclusion from NTPDES
Stormwater Permitting. Based on your submittal and signed certification of no exposure at the above
referenced facility, the Division is granting you conditional exclusion from permitting as provided for
under 40 CFR 126.22(g). We are also hereby rescinding your current permit Certificate of Coverage,
NCG050143.
Please note, that by our acceptance of your no-exposure certification, you are obligated to maintain no-
exposure conditions at your facility. If conditions change such that your facility can no longer qualify for
no-exposure exclusion, you are obligated to immediately obtain NTPDES permit coverage for your
stormwater discharge. Otherwise, the discharge becomes subject to enforcement as an un-permitted
discharge. Your conditional no-exposure exclusion expires in five years (May 13, 2015). At that time
you must re-certify with the Division, or obtain NPDES permit coverage for any stormwater discharges
from your facility.
Your conditional exclusion from permitting does not affect your facility's legal requirements to obtain
environmental permits that may be required under other federal, state, or local regulations or ordinances.
If you have any questions or need further information, please contact Jenifer Carter at (336) 7 71-4957, or
at [e-mail]
Sincerely,
keve W. Tedder
Surface Water Regional Supenisor
Winston-Salem eg-ional=1ice
Division of Water Quality
cc: WSRO files
SWP Central Files
CSarah--Young`Stormwater-Permitting-Unit:-No-Expostrre,Fil-e
Fran McPherson— Budget Office
North Carolina Division of VVater ouality,Winston-Salem Regional Office One
Location:565'Alaughloun Si.Winston-Salem,North Carolina 27107 NorthCarolina
Phone:[phone] FAX:[phone] Customer Service:1-67-1-623-6748
Internet imN.rncwalerquality.org ;Vahmally
Ar,Fquai Oportin y 1,,AYumaiive Acton Employer

Compliance Inspection Report
Permit: NCGNE0691 Effective: 05/14/10 Expiration: Owner: Tarheel Plastics
SOC: Effective: Expiration: Facility: Tarheel Plastics
County: Davidson 2018 E US Hwy 64
Region: Winston-Salem
Lexington NC 27292
Contact Person: John Collins Title: Phone: [phone]
Directions to Facility:
System Classifications:
Primary ORC: Certification: Phone:
Secondary ORC(s):
On-Site Representative(s):
On-site representative Craig Wilson Phone: [phone]
Related Permits:
NCG050143 Moll Industries Inc-Moll Industries, Inc
Inspection Date: 02/1 6120 1 2 Entry Time: 11:45 AM Exit Time: 12:00 PM
Primary Inspector: Jenifer Carter Phone: [phone]
Secondary Inspector(s):
Reason for Inspection: Routine Inspection Type: Compliance Evaluation
Permit Inspection Type: Stormwater Discharge, No Exposure Certificate
Facility Status: ❑ Compliant 0 Not Compliant
Question Areas:
■Miscellaneous Questions 0 Misc
(See attachment summary)
Page: 1

Permit: NCGNE0691 Owner-Facility: Tarheel Plastics
Inspection Date: 02/16/2012 Inspection Type: Compliance Evaluation Reason for Visit: Routine
Inspection Summary:
Met with Craig Wilson. Provided him with the new self-recirtification forms and infoorma#ion. Pallets (mostly refurbished)
being stored outside. Mr. Wilson said he would notify DWQ when they were covered so the site can be revisited.
Otherwise OK to continue with No Exposure certification.
Misc Yes No NA NE
Is the facility compliant? ■
nnn
Comment:
Page: 2

NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins Dee Freeman
Governor ; : Director Secretary
May 14, 2010
Tarheel Plastics LLC
Attn: Mr. John E. Collins
2018 E US Highway 64 Goa 4 Y-
Lexington,NC 27292
Subject: No-Exposure Certification NCGNE0691
Rescission of Permit NCG050143
Tarheel Plastics Inc.
Davidson County
Dear Mr. Collins:
The Division has reviewed your application for No-Exposure Certification for Exclusion from NPDES
StormNvater Permitting. Based on your submittal and signed certification of no exposure at the above
referenced facility, the Division is granting you conditional exclusion from permitting as provided for
under 40 CFR 126.22(g). We are also hereby rescinding your current permit Certificate of Coverage,
NCG050143.
Please note, that by our acceptance of your no-exposure certification, you are obligated to maintain no-
exposure conditions at your facility. If conditions change such that your facility can no longer qualify for
no-exposure exclusion, you are obligated to immediately obtain NPDES permit coverage for your
stormwater discharge. Otherwise, the discharge becomes subject to enforcement as an un-permitted
discharge. Your conditional no-exposure exclusion expires in five years (May 13, 2015). At that time
you must re-certify with the Division, or obtain NPDES permit coverage for any stormwater discharges
from your facility.
Your conditional exclusion from permitting does not affect your facility's legal requirements to obtain
environmental permits that may be required under other federal, state, or local regulations or ordinances.
If you have any questions or need further information, please contact Jenifer Carter at [phone], or
at [e-mail]
Sincerely,
txL %
teve W. Tedder
Surface Water Regional Supervisor
Winston-Sa em egiona Mice
Division of Water Quality
cc: �W..SRO_files
SLAT Central Files
Sarah Young— Stormwater Permitting Unit: No- Exposure File
Fran McPherson—Budget Office
North Carolina Division of Water Quality,Winston-Salem Regional Office
Location:555 Wauahiown St Winston-Salem,North Carolina 27107 One1,
Phone:[phone] FAX:[phone] Customer Service:1-c77-623-6748 Nor/t t C//ay�rohna
intemet:www.ncvjaterquality org ;V to a`l
An Fquall Oppo:tuni[y'.A u'mative Action Employer

FOR AGENCY USE ONLY-
4 Date Received
Division of Water Quality/Surface Water Protection Year Niontit Day.
..�...�.� ..v.
���E�� National Pollutant Discharge Elimination System N Certificate of Coverage
lk .„C „U t;�,. _ NO EXPOSURE CERTIFICATION for Exclusion
Fxv.rr�rrrr+xn 0m, .RrS0..3 rz
NCGNE0000
NO EXPOSURE CERTIFICATION 'Please check here-if this is--a renewal: ❑ RENEWAL
National Pollutant Discharge Elimination System application for exclusion from a Stormwater Permit based
on NO EXPOSURE:
Submission of this No Exposure Certification constitutes notification that your facility does not require a
permit for stormwater discharges associated with industrial activity in the State of North Carolina because
it qualifies for a no exposure exclusion. A condition of no exposure at'an industrial facility means all
industrial materials and activities are protected by a storm resistant shelter(with some exceptions) to
prevent exposure to rain, snow, snowmelt, and/or runoff.
For permitted facilities in North Carolina, DWQ must approve your application for No
Exposure Certification before this exclusion is effective. Until you are issued a No
Exposure Certification and your NPDES permit is rescinded, your facility must continue
to abide by the terms and conditions of the current permit.
Industrial materials or activities include, but are not limited to: material handling equipment or activities,
industrial machinery, raw materials, intermediate products, by-products, final products, or waste products.
Material handling activities include the storage, loading and unloading, transportation, or conveyance of
any raw material, intermediate product, final product or waste product. A storm resistant shelter is not
required for the following industrial materials and activities: drums, barrels, tanks, and similar containers
that are tightly sealed, provided those containers are not deteriorated and do not leak. "Sealed"means
banded or otherwise secured and with locked or non-operational taps or valves;adequately maintained
vehicles used in material handling;and final products, other than products that would be mobilized in
storm water discharges (e.g., rock salt).
A No Exposure Certification must be provided for each facility qualifying for the no exposure exclusion. In
addition, the exclusion from NPDES permitting is available on a facility-wide basis only—not for individual
outfalls. .If any industrial activities or materials are, or will be, exposed to precipitation, the facility is not
eligible for the no exposure exclusion. By signing and submitting this No Exposure Certification form, you
certify that a condition of no exposure exists at this facility or site and are obligated to comply with the
terms and conditions of 40 CFR 122.26(g).
You are required to reapply for the No Exposure Exclusion once every five (5) years.
For questions,please contact the DWQ Regional Office for your area. (See page 6)
(Please print or type)
1) Mailing,address of owner/operator address to which all certification correspondence will be mailed :
Narne- Adr Aeve
Contact d ., 6
Street Address d O
City LeKState ZIP Code
Telephone No. 33 G Fax: 3 �� a?
R€c€iv€D
N.C.Deot of,ENR
Page 1 of 7 MAY 1 12010
Winston-Salem
SWU-NE-021309 Regional Office Last revised 2/13/2009

4 T • '
NCGNE0000 No Exposure Certification 1
2) Location of facility producing discharge:Facility Name ��l/��nn/ f�5 A"_S
Facility Contact ` O
Street Address doll5
City Le State NL ZIP Code a7-217—
County ;
Telephone No. 3'�� 2�3- �I 3/ Fax: 33 14 3
3) Physical location information:
Please provide a narrative description of how to get to the facility (use street names, state road numbers, and
distance and direction from a roadway intersection). e4 el;"JWvM
, - aJ ,r a.r l3 e
(A copy of a map with the facility clearly located on it should be included with the certification application.)
4) Is the facility located on Native American Lands? ❑ Yes No
5) Is this a Federal facility? ❑ Yes ❑ No
6) Latitude35�07 r 1102 ')A/ Longitude& 12'29 A; (deg., min., seconds)
7) This NPDES No Exposure Exclusion application applies to which of the following:
❑ New or Proposed Facility Date operation is to begin
Existing Date operation began
❑ Renewal of existing No Exposure Certification Certification No.: NCGNE
8) Was this facility or site ever covered under an NPDES Stormwater Permit? ER4S ❑ No
If yes, what is the NPDES Permit Number?NC p5 01LP3
9) Standard Industrial Classification:
Provide the 4 digit Standard Industrial Classification Code (SIC Code) that describes the primary industrial
activity at this facility
SIC Code:
10) Provide a brief description f the types of industrial activities and products produced at this facility:
O
11) Does this facility have any Non-Discharge permits (ex: recycle permits)?
❑ No
Yes
If yes, list the permit numbers for all current Nan-Discharge permits for this facility:
Page 2 of 7
SWU-NE-021309 Last revised 2/13/2009

NCGNE0000 No Exposure Certification
Exposure Checklists (12. - 14.)
12) Are any of the following materials or activities exposed to precipitation, now or in the foreseeable
future? (Please check either "Yes" or "No.") If you answer "Yes" to any of these items, you are not
eligible for the no exposure exclusion.
a. Using, staring, or cleaning industrial machinery or equipment, and areas where 0 Yes -6 No ❑ NIA
residuals from using, storing or cleaning industrial machinery or equipment remain I'
and are exposed to stormwater
b. Materials or residuals on the ground or in stormwater inlets from spills/leaks ❑ Yes No ❑ NIA
c. Materials or products from past industrial activity 0 Yes No ❑ NIA
d. Material handling equipment (except adequately maintained vehicles) ❑ Yes No ❑ NIA
e. Materials or products during loading/unloading or transporting activities ❑ Yes [(No ❑ NIA
f. Materials or products stored outdoors (except final products intended for outside ❑ Yes V No ❑ NIA
use [e.g., new cars] where exposure to stormwater does not result in the discharge
of pollutants)
g. Materials contained in open, deteriorated or leaking storage drums, barrels, tanks, ❑ Yes �A No ❑ NIA
and similar containers
•h. Materials or products handled/stored on roads or railways owned or maintained by ❑ Yes IANo ❑ NIA
the discharger
i. Waste material (except waste in covered, non-leaking containers [e.g., dumpsters]) ❑ Yes 1�No ❑ NIA
j. Application or disposal of process wastewater (unless otherwise permitted) ❑ Yes No ❑ NIA
k. Particulate matter or visible deposits of residuals from roof stacks and/or vents not ❑ Yes I No ❑ NIA
otherwise regulated (i.e., under an air quality control permit) and evident in the
stormwater outflow
I. Empty containers that previously contained materials that are not properly stored ❑ Yes )kNo ❑ N/A
(#.e., not closed and stored upside down to prevent precipitation accumulation)
m. For any exterior ASTs, as well as drums, barrels, tanks, and similar containers © Yes A No ❑ NIA
stored outside, has the facility had any releases in the past three (3) years?
13) Above Ground Storage Tanks (ASTs): If you answer "No" to any of the following items, you are.not
eligible for the no exposure exclusion.
a. Are exterior ASTs or piping free of rust, damaged or weathered coating, pits, or ❑ Yes 4No NIA
deterioration, or evidence of leaks?
b. Is secondary containment provided for all exterior ASTs? If so, is it free of any ❑ Yes ❑ No NIA
cracks, holes, or evidence of leaks, and are drain valves maintained locked shut?
Page 3 of 7
SWU-NE-021309 Last revised 2/13/2009

NCGNE0000 No Exposure Certification
14) Secondary Containment: If you answer "No" to any of the following items, you are not eligible for the
no exposure exclusion.
a. Is secondary containment provided for single above ground storage containers ❑ Yes ❑ No NIA
(including drums, barrels, etc.) with a capacity of more than 660-gallons?
b. Is secondary containment provided for above ground storage containers stored ❑ Yes ❑ No NIA
in close proximity to each other with a combined capacity of more than 1,320- I
gallons?
c. Is secondary containment provided for Title III Section 313 Superfund ❑ Yes ❑ No NIA
Amendments and Reauthorization Act (SARA) water priority chemicals"?
d. Is secondary containment provided for hazardous substances" designated in 40 ❑ Yes ❑ No l� NIA
CFR §116?
e. Are release valves on all secondary containment structures locked? ❑ Yes ❑ No NIA
15) Hazardous Waste:
a. Is this facility a Hazardous Waste Treatment, Storage, or Disposal Facility? ❑ Yes X No ❑ NIA
b. Is this facility a Small Quantity Generator (less than 1000 kg. of hazardous waste ❑ Yes )(No ❑ NIA
generated per month) of hazardous waste?
c. Is this facility a Large Quantity Generator (1000 kg. or more of hazardous waste ❑ Yes No Cl NIA
generated per month) of hazardous waste?
If you answered yes to questions b. or c., please provide the following information:
Type(s) of waste:
How is material stored:
Where is material stored:
How many disposal shipments per year:
Name of transport 1 disposal vendor:
Vendor address:
Footnotes to Questions 14) c. & d.
*Note that amounts below the 660-gallon (single) and 1,320-gallon (combined) bulk storage minimums require
secondary containment. However, some exceptions may be made for de minimis amounts of certain substances,
and/or other qualifiers, as described in the exemptions from reporting requirements of Title III SARA 313 in 40 CFR
§372.38.
**Note that amounts below the 660-gallon (single) and 1,320-gallon (combined) bulk storage minimums require
secondary containment. However, some exceptions may be made for amounts less than the Reportable Quantities
of the hazardous substances listed in 40 CFR §117.3.
Page 4 of 7
SWU-NE-021309 Last revised 2/13/2009

NCGNE0000 No Exposure Certification
16) Other information: If you answer "Yes" to any of the following items, you might not be eligible for the
no exposure exclusion. A more in-depth evaluation of the site circumstances may be required.
a. Does your facility store used, recycled, or otherwise reclaimed pallets outside? ❑ Yes No ❑ NIA
b. Does your facility have coal piles on site? ❑ Yes No ❑ NIA
c. Does your facility store other fuel sources outside in piles, such as wood chips, ❑ Yes ` No ❑ NIA
sawdust, etc.?
d. Does your facility have air emissions associated with its industrial activity (e.g., ❑ Yes No © NIA
degreasing operations, plating, painting and metal finishing)? If so, describe the
industrial activity:
e. It you answered yes to d., are those emissions permitted by an Air Quality Permit? ❑ Yes ❑ No N/A
Please specify:
f. Please list any other environmental program permits (federal, state, etc.) not
specified earlier in this application (such as Hazardous Waste Permits, etc.):
Permit: Program:
Permit: Program:
Permit: Program:
Permit: Program:
Permit: Program:
Permit: Program:
Permit: Program:
Page 5 of 7
SWU-NE-021309 Last revised 2/13/2009

NCGNE0000 No Exposure Certification
17) Certification:
I certify under penalty of law that I have read and understand the eligibility requirements for claiming a condition of"no
exposure"and obtaining an exclusion from NPDES stormwater permitting.
I certify under penalty of law that there are no discharges of stormwater contaminated by exposure to industrial activities
or materials,from the industrial facility or site identified in this document(except as allowed under 40 CFR 122.26(g)(2)).
I understana that I am obligated to submit a no exposure certification form once every five U years to the North Carolina
Division of Water Quality and, if requested,to the operator of the local municipal separate storm sewer system (MS4) into
which the facility discharges (where applicable). I understand that I must allow the North Carolina Division of Water
Quality, or MS4 operator where the discharge is into the local MS4, to perform inspections to confirm the condition of no
exposure and to make such inspection reports publicly available upon request.
In the event that the site no longer qualifies for a No Exposure Exclusion, I understand that I must obtain coverage under
an NPDES permit prior to any point source discharge of stormwater from the facility. Additionally, I certify under penalty of
law that this document and all attachments were prepared under my direction or supervision in accordance with a system
designed to assure that qualified personnel properly gathered and evaluated the information submitted. Based on my
inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the
information, the information submitted is to the best of my knowledge and belief true, accurate and complete. I am aware
that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for
knowing violations.
I certify that I am familiar with the information contained in this application and that to the best of my knowledge and belief
such information is true, complete, and accurate.
Printed Na a of Person Signing: i
Title:
{Sig Lure of Applicant) (Date Signed)
Please note: This application for the No Exposure Exclusion is subject to approval by the
NCDENR Regional Office prior to issuance. The Regional Office may inspect your facility for
compliance with no exposure conditions prior to'that approval. The Regional Office may also
inspect your facility at any time in the future for compliance with the No Exposure Exclusion.
North Carolina General Statute 143-215.6 B(i) provides that:
Any person who knowingly makes any false statement, representation,or certification in any application,record, report,plan,or other
document filed or required to be maintained under this Article or a rule implementing this Article;or who knowingly makes a false
statement of a material fact in a rulemaking proceeding or contested case under this Article;or who falsifies,tampers with,or knowingly
renders inaccurate any recording or monitoring device or method required to be operated or maintained under this Article or rules of the
[Environmental Management]Commission implementing this Article shall be guilty of a Class 2 misdemeanor which may include a fine
not to exceed ten thousand dollars($10,000).
There is currently no fee for a No Exposure Exclusion.
Page 6 of 7
SWU-NE-021309 Last revised 2/13/2009

NCGNE0000 No Exposure Certification
Final Checklist
This application should include the following items:
❑ This completed application and all supporting documentation.
❑ A map with the location of the facility clearly marked.
❑ If this is a renewal, indicated current NCGNE number in Question 7.
❑ If the site currently has an NPDES Stormwater Permit, be sure to indicate the permit number in Question 8.
Mail the entire package to:
Stormwater Permitting Unit
Division of Water Quality
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Note
The submission of this document does not guarantee the issuance of a No Exposure Exclusion.
For questions, please contact the DWQ Regional Office for your area.
DWQ Regional Office Contact Information:
v �Yl/111 4tp - - -3 x .s�". •<'°'_" yr..
Asheville Office ...... [phone] �
Fayetteville Office ... [phone]g at s
Mooresville Office ... [phone]
Raleigh Office ........ [phone] �
Washington Office ...[phone] 3 .wt """' 00
Wilmington Office ... [phone]
Winston-Salem ...... [phone]
Central Office .........[phone]
S
will ngton
y
Page 7 of 7
SWU-NE-021309 Last revised 2/13/2009

EXHIBIT C
BILL OF SALE
FOR VALUE RECEIVED, and in accordance with that certain Asset Purchase
Agreement (the "Purchase Agreement"), incorporated herein by reference and made a
part hereof, and dated as of December 31, 2009, by and between Moll Industries, Inc., a
Delaware corporation (the "Seller") and Tarheel Plastics, LLC, a North Carolina Limited
Liability Company (the "Buyer"), the Seller does hereby sell, assign., transfer, deliver,
and convey to the Buyer all rights, title and interest in and to all of the Acquired Assets,
but expressly excluding the Excluded Assets (as such terms are defined in the Purchase
Agreement).
TO HAVE AND TO HOLD said Acquired Assets unto Buyer, its successors and
assigns, and Seller does hereby represent and warrant that such assets are transferred to
Buyer free and clear of any security interests, liens, adverse claims, encumbrances or
other restrictions whatsoever, except for Permitted Liens (as provided under the Purchase
Agreement); provided, however, to the extent that the Acquired Assets are not assignable
without consent of a third party, this Bill of Sale shall not constitute an assignment or
assumption, or attempted assignment or assumption, thereof if such assignment or
assumption, or attempted assignment or assumption, would constitute a breach thereof.
THIS BILL OF SALE is given pursuant and subject to the Purchase Agreement,
and in the event of any conflict between the tenns hereof and those of the Purchase
Agreement, the Purchase Agreement shall be deemed controlling.
[Signatures on the next page.]
AUS:622939.2

s
IN WITNESS WHEREOF, the parties hereto have caused this Agreement to be executed
as of the date first above written.
BUYER:
TARHCEL'PLASTICS,LLC
By:
Name:
Title:
SELLER:
MOLL-INDUSTRi ,iNC.
By: f
Na It)
0
Ti e:
AUS_e18145.10 -29-
--

�oF VdATF9p Beverly Eaves Perdue,Governor
7 r Dee Freeman,Secretary
>_ r- North Carolina Department of Environment and Natural Resources
Coleen H.Sullins,Director
Division of Water Quality
SURFACEWATER PROTECTION.SECTION
........ .. -..
PERMiT NAME/OWNERSHIP CHNNGE'FORIVI,` _
I. Please enter the permit number for which the change is requested.
NPDES Permit (or) Certificate of Coverage
N e s a iv e 0 a
II. Permit status Vrior to requested change.
a. Permit issued to (company name):
b. Person legally responsible for permit:
First MI Last
— • Title
APR L 3 2010 �n18lsJ yS � �y
{ Permit Holder Maili g Address
DENR <:. `s f:piJ,4LITY
We�<A. .7E�rater Sranctr City State Zip
Phone Fax
c. Facility name (discharge):
d. Facility address:
Address
City State Zip
e. Facility contact person: ( }
First 1 MI/Last Phone
III. Please provide the following for the requested change (revised permit).
a. Request for change is a result of: Change in ownership of the facility
Name change of the facility or owner
If other please explain: '
b. Permit issued to(company name): IAr ee S,icS L.L
c. Person legally responsible for permit: <T—A., E
First MI Last
PIS m�►�
Title
Permit Holder Mailing Address
ity State Zip
{33to) ��- Z131 ��li�„s�-��j,ec_f .P��s�t4s• Cam
Phone r E-mail Address
d. Facility name (discharge): -7—Af/e j 101AS7ls- LGG
e. Facility address: ,�,a I g i�q CA- LA ,- (a'f
Address
Lt N-c-
City State Z
f. Facility contact person: V�/I � t���`1
First MI Last
31 6/1. ree/PI r-17�J• 4P"'-
Phone E-mail Address
Revised 812008

PERMIT NAME/OWNERSHIP CHANGE FORM
Page 2 of 2 '\
IV. Permit contact.information (if different from the person legally responsible for the permit)
Permit contact:
First MI Last
Title
Mailing Address
City State Zip
( )
Phone E-mail Address
V. Will the permitted facility continue to conduct the same industrial activities conducted prior
this ownership or name change?
Yes
❑ No (please explain)
VI. Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS
ARE INCOMPLETE OR MISSING:
❑ This completed application is required for both name change and/or ownership change
requests.
[$ Legal documentation of the transfer of ownership(such as relevant pages of a contract deed,
/ � or a bill of sale) is required for an ownership change request. Articles of incorporation are
not sufficient for an ownership c ange.
�........................... G.....� ............................................................................
The certifications below trust be completed and signed by both the permit holder prior to the change, and
the new applicant in the case of an ownership change request. For a name change request, the signed
Applicant's Certification is sufficient.
PERTMITTEE CERTIFICATION (Permit holder prior to ownership change):
1, , 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 is not included, this application package will be
returned as incomplete.
0km
Signature / Date
APPLICANT CERTIFICATION
1, , 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 is not included, this application package will be
returned as incomplete.
Signature Date
...................................
PLEASE SEND THE COMPLETE APPLICATION PACKAGE TO:
Division of Water Quality
Surface Water Protection Section
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Revised 7I2008