NC0000019_Signatory Authority_20150521

NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Resources
Pat McCrory Donald R. van der Vaart
Governor WATER QUALITY PERMITTING SECTION Secretary
PERMIT NAME /OWNERSHIP CHANGE REQUEST
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. ( f o r which the change i s requested: I NC 0 0 0 00 19
or
Certificate of Coverage #: I N C G 5
II. Existing Permittee Information:
a. Permit issued to (company name): United Chemi -Con, Inc
b. Person legally responsible for permit: Yoshi Narita
First MI Last
RECEIVEDIDENRIDWR Vice President of Operations
Title
21 2015 185 McNeil Rd.
mAY Permit Holder Mailing Address
Water Qua_ l�1_ Lansing NC 28643 -
Permiltin9 11 City State Zip
(336) 384 -2551 (336) 384 -6927
Phone Fax
c. Facility name: United Chemi -Con, Inc
d. Facility's physical address:
e. Facility contact person:
185 McNeil Rd
Address
Lansing NC
City State
Gale D. Howell, Jr
First / MI / Last
28643
Zip
(336) 384 -6917
Phone
III. Applicant Information:
a. Request for change is a result of: ❑ Change in ownership of the facility
❑ Name change of the facility or owner
bother please explain: Change of staff assignment
b. Permit issued to (company name): United Chemi -Con, Inc
c. Person legally responsible for permit: Steve V Katz
First MI Last
Plant Manager
Title
185 McNeil Rd
Permit Holder Mailing Address
Lansing NC 28643 -
City State Zip
(336) 384 -6918 skatz(achemi- con.com
Phone E -mail Address
Page 1 of 2 Revised 710112014

d. Facility name:
e. Facility's physical address:
f. Facility contact person:
United Chemi -Con, Inc
185 McNeil Rd
Address
Lansing NC
28643
City State
Zip
Gale D
Howell, Jr
First MI
Last
Environment Health and Safety Manager
Title
(336) 384 -6917 bhowellpchemi- con.com
Phone E -mail Address
IV. Will the permitted facility continue to conduct the same commercial/industrial activities conducted prior to
this ownership or name change?
® Yes
❑ 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 BE RETURNED UNPROCESSED IF ITEMS ARE
INCOMPLETE OR MISSING:
1. 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
required for an ownership change request. Articles of incorporation are not sufficient for an ownership change.
Applicable regulations: 40 CFR 122.41, 40 CFR 122.61 and 15A NCAC 02H .0114
...................................................................................... ...............................
The certifications below must be completed and signed by both the permit holder prior to the change (Permittee), and the
new applicant in the case of an ownership change request. For a name change request, the signed Applicant's Certification
is sufficient.
PERMITTEE CERTIFICATION (Permit holder prior to ownership change):
I, , 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
APPLICANT CERTIFICATION
Date
I, S. Katz, 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.
��� ��_ _5_11f //J--
I/ SignauWee Date
* * * * * * * * * * * * * * * * * * * * * * * * **
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 NAME /OWNERSHIP CHANGE REQUEST
Page 2 of 2 Revised 710112014