WI0600244_Application_20240923

North Carolina Department of Environmental Quality HEGOV& ,
Division of Water Resources 13EP 2 3
PERMIT NAME/OWNERSHIP CHANGE APPLICATION FORM
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I. INSTRUCTIONS
1. Complete this form in its entirety as follows:
(a) Change of Ownership Provide the information in Parts II and III and submit legal documentation of the
transfer of ownership such as a contract,deed,article of incorporation,etc. The certifications in part IV
must be signed by both the current permit holder,if available,and the new applicant(s).
(b) Name Change Only.—Provide the information in Parts U and III. Sign the certification for the new
applicant in part IV.2.
2. Submit the properly completed form to the address on bottom of Page 2.
It. CURRENT PERMIT INFORMATION
1. Permit Number: WI0600244
2. Permittee name(s): Empower Brands,Inc.
3. For Business/Governmental Agency-Permit signing official's name and title: Jim Skaggs—Sr. Director,
Corporate Global.EHS&Compliance Assurance
(Person legally responsible for permit)
4. Mailing Address:85 Arbor Circle
City: Stillwater State: OK ___ Zip: 74074
Telephone number: [phone] Fax number:
EMAIL,Address: jim.skaggsospectrumbrands.com
5. Physical Address of Facility/Well(s)(if different than mailing address)
17160 Watch Plant Road
City: Laurinburg County: Scotland Zip: 28352
III. NEW OWNER/NAME INFORMATION
I. This request for a permit change is a result of:
a.Change in ownership of property/company
X b.Name change only
_c.Other(please explain):
Pennit/Name Change of Ownership Form Rev.2-18-2020 Page 1

2. New Owner's names)as listed on the property deed(Please Print/or Type):
Name Change Only to: Empower Brands,LLC
3. If Business or Governmental Agency- Permit signing official's name and title: Jim Skaggs — Sr. Director,
Corporate Global EHS&Compliance Assurance
(Person legally responsible for permit)
4. Mailing Address: 85 Arbor Circle
City:Stillwater State: OK Zip: 74074________
Day/Cell Phone No.[phone] Fax number:C___)NIA
EMAIL Address:[e-mail]
IV. CERTIFICATION
1. Current Permittee's Certification(Please print or type):
1, attest that this application for 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 package will be returned as incomplete. I understand I will continue to be responsible for
compliance with the current permit until a new permit is issued.
2. New Applicant(s)'s Certification(Please print or type):
I/We, Jim Skaggs attest that this
application for 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 package will be returned as
incomplete. I further certify that I will operate and maintain the permitted facility in accordance with the permit
and related regu toffy requirements. /
Signature: Dater C1
Signature: Date:
SUBMIT THE COMPLETE APPLICATION PACKAGE VIA ONE OF THE FOLLOWING METHODS:
U.S. Postal Service: Courier/Special Delivery/In Person:
Ground Water Resources Section Ground Water Resources Section
NC Division Of Water Resources NC Division Of Water Resources
1636 Mail Service Center 512 North Salisbury Street
Raleigh,NC 27699-1636 Raleigh,NC 27604
Telephone Number: [phone]
Permit/Name Change of Ownership Form Rev.2-18-2020 Page 2