NC0003719_Ownership Change_20160311

Division of Water Resources
Pat McCrory Donald R.van der Vaart
Governor WATER QUALITY PERMITTING SECTION Secretary
PERMIT NAME/OWNERSHIP CHANGE REQUEST
—-- 1 his form is for ownership changes or manic chanes of NPDES i%astertater•permits.
• -Periniite_ references the e'i;i ine hermit holder
•- ":applicant`retcrences the entity applvine for the ownership ninny change.
I. NPDES Permit No.((or which the change is requester): N C 0 0 O 3 7
or
— /
Certificate of Coverage#: N C G 5
H. Existing Permittee Information:
a. Permit issued to(company name): �-( A L 1-C
_ me, CGS
—
h. Person legally responsible for permit:
First MI Last
R PC.F \ — Title --
M4R 1 12015 Permit I{older Mailing Address
LAM;I:! TION City State Zip
r i ORS;IATInt�'PRoirr.C..pI;^
Phone Fax
c. Facility name:
d. Facility's physical address:
Address
City State Zip
e. Facility contact person: Do/tald 4llhr, A+
First / Ml ; Last Phone
III. Applicant Information: -/
a. Request for change is a result of: 1 ( hant;e in ownership of the facilitygiiii
change of the facility or owner
!lather please explain:
b. Permit issued to(company name): 0 K 1I e •
c. Person legally responsible for permit: �tlQ.l. H k
view ---- e.� r;�.__ son
First Mt Last
,3.2 !t: Title ---- ---- ---- -
-'68 Ccc,/ar tree 1f Rd— ..
Permit Holder Mailing Address
FGyeI4ev,•lid eve — 830/
City State Zip
(r/1D) 413.8.?8r r1 Hcaa(I",'G k0,1 O d?ftA_Mtazj5.cc
Phone E-mail Address
Page I oft Revised 1/01/1014

F 40-e,,,ell4 NG ?83.0_1
City State Zip
t: Facility contact person: tin u�rt 1114 'gkL_
First Ml Last
nL
Title
_ Ma)Y33-fi..z27. -
Phone E-mail Address
IV. Will the permitted facility continue to conduct the same commercial/industrial activities conducted prior to
this o}vnership or name change?
Q/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:
I. This completed application is required for both name change and/or ownership change requests.
2. I.egal 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 he completed and siened by hoth 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):
1, ,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 arc not completed and that if all required
supporting information is not included,this application package will he returned as incomplete.
Signature Date
APPLICANT CERTIFICATION
I, HP}If ,attest that this application for a name.'owttership 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 no ncluded,this application package will be returned as incom fete
t♦ •
.r/ � maim—. 3Ib _�ea
Signature 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 Cl1ANGE REQUEST
Page 2 of 2 Revised 7/01'2014
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Wastewater Branch
Water Quality Permitting Section f--( '-}-R/p ,.
Division of Water Resources
1617 Mail Service Center MAR Y J 2016
Raleigh,NC 27699-1617
Clljt:
Subject: Delegation of Signature Authority
INF t?Rr1ln'fl(1;‘1 f-viOCES S!NG UNI T
Facility Name: IDS 111Aince, 41-e — —
NPDIE S Permit iii umber: N I C a 1 v I o 131 ri l l y I
To Whom It May Concern:
By notice of this letter, [hereby delegate signatoty authority to each of the following individuals for all
permit applications,discharge monitoring reports,and other information relating to the operations at
the subject facility as required by all applicable federal,state,and local environmental agencies
specifically with the requirements for signatory authority as specified in 15A NCAC 2B.0506.
Individual #1 Individual#2(if applicable)
Natter a
6-
4,r7 Slater �p ff/16 , tif_.
32 16 Cedar C ree IC 1 3 2 It. Cedar Gree!(
Nitling Address
Fuyev:!!e 1NC - 1130E--- — FA GHei,.'1(e , 1VC 0830 -
tystcai Mdressl
•
(ifdf�j�reiiC)� r�, I
ipxa1A dress [GSla�tr�C otve,40, , ,,r DAIli,r;3kIG OAKAM-r; . on
!.•Y - 8.21
Mo6t1e l'hr�ne' .
If you have any questions regarding this letter,please feel free to contact me at either the phone
number or email address below.
Sincerely,
✓n'i —
Authorized Signing t'cial's Signature
WEAJble)46.0A) ?"myr //AAA-6E4
Authorized Signing Official's Name(type crpri,a) Title
Mailing Address
Email AddressOffice Phone Mobile Phone
cc: Ft?0 Regional Office,Water Quality Permitting Section
(Enter region name) --