NC0003671_Owner Name Change_20160729

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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
*03y; , -E x°g PERMIT NAME/OWNERSHIP CHANGE REQUES " ,,A.ig
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 000 3 6 7 1
or
Certificate of Coverage#: N C G 5
II. Existing Permittee Information:
a. Permit issued to(company name): Magellan Terminals Holdings, L.P.
b. Person legally responsible for permit: Melanie Little
RECEIVED1NCDEUDWR First MI Last
vice President of Operations
J U L 2 9 2016 Title
One Williams Center, MD27
Water Quality Permit Holder Mailing Address
Permitting Section Tulsa OK 74172-
City State Zip
[phone] [phone]
Phone Fax
c. Facility name: Greensboro II Terminal
d. Facility's physical address: 7109 West Market Street
Address
Greensboro NC 27409-
City State Zip
e. Facility contact person: Ruben Qualls [phone]
First / MI / Last Phone
III. Applicant Information:
a. Request for change is a result of: ❑ Change in ownership of the facility
0 Name change of the facility or owner
If other please explain: Change in Responsible Official
b. Permit issued to(company name): Magellan Terminals Holdings,L.P.
c. Person legally responsible for permit: Rick Fahrenkrog
First MI Last
Director, Environmental Health& Safety
Title
One Williams Center, MD OTC-8
Permit Holder Mailing Address
Tulsa OK 74172-
City State Zip
[e-mail]
[phone] m
Page 1 oft Revised 7/01/2014

d. Facility name: Greensboro II Terminal
e. Facility's physical address: 7109 West Market Street
Address
Greensboro NC 27409-
City State Zip
f. Facility contact person: Ruben Qualls
First MI Last
Area Supervisor
Title
[phone] [e-mail]
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?
0 Yes
0 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:
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
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 021I.0114
The certifications below must be completed and signed by kat 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 Date
APPPLIICANT CERTIFICATION
I,K-Y/ 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.
41.:tore Date
PLEASE SEND THE COMPLETE APPLICATION PACKAGE TO:
Division of Water Resources
Water Quality Permitting Section
1617 Mail Service Center
NPDES PERMIT NAME/OWNERSHIP CHANGE REQUEST
Page 2 of 2 Revised 7/12014