NC0000892_Owner (Affiliation Change)_20240725

ROY COOPER
MIC HAEL S. REGAN
LINDA CULPEPPER
Water' Resources
ENVIRONMENTAL QUALITY
PERMIT NAME/OWNERSHIP CHANGE FORM
1. CURRENT PERMIT INFORMATION:
Permit Number: NC00 0 1 0 1 8 1 9 1 2 or NCG5 1 1 1 1
1. Facility Name: Arclin USA, LLC
II. NEW OWNERINAME INFORMATION:
1. This request for a name change is a result of:
a. Change in ownership of property/company
b. Name change only
X c. Other (please explain): Change in Responsible Official Only
2. New owner's name (name to be put on permit):
3. New owner's or signing official's name and title:
4. Mailing address: 790 Corinth Rd.
State: NC Zip Code: 27559
E-mail address: [e-mail]
Daniel Cox
(Person legally responsible for permit)
Deputy Director of Manufacturing
(Title)
City: Moncure
Phone: ( 334 ) 343 - 8101
THIS APPLICATION PACKAGE WILL NOT BE ACCEPTED BY THE DIVISION UNLESS ALL OF THE
APPLICABLE ITEMS LISTED BELOW ARE INCLUDED WITH THE SUBMITTAL.
REQUIRED ITEMS:
1. This completed application form
2. Legal documentation of the transfer of ownership (such as a property deed, articles of
incorporation, or sales agreement)
[see reverse side of this page for signature requirements]
State of North Carolina I Environmental Quality I Water Resources
1617 Mail Service Center I Raleigh, NC 27699-1617
9 f 9 807 6300 9t9-807-6389 FAX
htips://deq.nc. gov/about/di visions/water-resources/water-resources-permits/wastewater-branch/npdes-wastewater-permits

NPDES Name & Ownership Change
Page 2 of 2
Ap licant's Certification:
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 and attachments are not included, this application
packag&-wfli-b-u7eturn��as incomplete.
Signature:
Date: 'j'
THE COMPLETED APPLICATION PACKAGE, INCLUDING ALL SUPPORTING
INFORMATION & MATERIALS, SHOULD BE SENT TO THE FOLLOWING ADDDRESS:
NC DEQ ! DWR 1 NPDES
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Version 1112017