NC0065986_Ownership Change_20160202

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RCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Resources
Pat McCrory Donald R. van der Vaart
Governor WATER QUALITY PERMITTING SECTION Swetary
PERMIT NAMFJOWNERSMII €`"E .RF FST
• 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 0 0
or
Certificate of Coverage €1: N C G 5
11. Existing Permittee Information: _
a. Permit issued to (company name): (� f�
b. Person legally responsible for permit:
First J Ml Last
c. Facility name:
d. Facility's physical address:
e. Facility contact person:
III. Applicant Information:
a. Request for change is a result of:
If other please explain: Nlio
b. Permit issued to (company name):
c. Person legally responsible for permit:
Page t of 2
0 2 2016
Title
Permit H.1,4- LA.M„g Address
EQ SL" 5 01 ag u y a
City 0 State Zip
Done
ray I S S�i�d 1 U t5
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Address
city JJ Sta zip
First / MI / Last Phone
❑ Change in ownership of the facility
Name change of the facility or owner
Gt= n F- Pee.Mt r FF'
uv-VJUQV I1-e L IL-S FrnMt-(XL1A-)(7-YU /j55 (/}7)Aa1
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First L—_ VA h MI Last 5C7/1 r'� j
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Title
P it Holder Mailing Address
� V , NC 2-P)75-1
`City U State zip
(1�)3) 73o r��y he-jr-,6 10„&1
Phone E-mail A
Revised 71011201

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d. Fmility name: �O i✓pOJ� (4t/ LS
e. Facility's Physical address: LoT e)13 - eO MNT1a-/ L Tim / L
,1 Address
Gf_ V4!4 AIC 2-875/
city zipf. Facility contact person: IP 72:>, i ES
First ,Q MI Last Q
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�j �nlLe
(GVJ) 7N' 1 U ?4 r} �f�N� I D1ll�s L 9 A7/i/Lr�l�1�
Phone E-mail AddresY
Will the permitted tecflfry continue to conduct the same commerckMadustrial activities conducted prior to
this,ownership or name change?
CJ es
❑ 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:
I . 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
n oulred for an ownership change request. Articles of incorporation are not sufficient for an ownership change.
....................A licabla regula>ions: 40 CFR 122A 1, 40 CFR 122.61 and 15A NCAC 02H .0114
.........................................................................
The certifications below must be completed and signed by hg& the permit holder prior to the change (Permitteel and the
new applicant In the case of an ownership change request. For a name change request, the signed Applicant's Certification
is =fTcient.
PERMITTEE 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. 1 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.
Sw ature Date
APPLICANT CERTIFICATION
1, attest that this application for a name/ownership change has been reviewed and is a0cu ate and complete to the best
of my knowledge. i mi that if all required parts of this application are not completed and that if all required
supporting m is kuded, this application package will be returned as . lete.
9 0/
rgnatrue Date
.............Nr�tR•Nf•f+
PLEASE SEND THE COMPLETE APPLICATION PACKAGE TO:
Division of Water Resources
Water Quality Permitting Section
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
NPDES PERMIT NAMEAO WNERSMP CHANGE REQUEST
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