NC0005126_Owner Name Change_20150716

Auir• A
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.(for which the change is requested): N C 0 0 0 5 1 2 6
or
Certificate of Coverage#: N C G 5
H. Existing Permittee Information:
a. Permit issued to(company name): Tyson Foods, Inc d/b/a River Valley Animal Foods
b. Person legally responsible for permit: Gregg Wikstrom
First MI Last
Plant Manager
Title
501 Sheffield Road
Permit Holder Mailing Address
Harmony NC 28634-
City State Zip
[phone] [phone]
Phone Fax
c. Facility name: Tyson Foods, Inc d/b/a River Valley Animal Foods
d. Facility's physical address: 501 Sheffield Road
Address
Harmony NC 28634-
City State Zip
e. Facility contact person: Kevin T Haynes [phone]
First / MI / Last Phone
HI. Applicant Information:
a. Request for change is a result of: ❑ Change in ownership of the facility
® Name change of the facility or owner
If other please explain: Legal department has advised that it is critical that the proper legal entity
appear on all permits and government correspondence
b. Permit issued to(company name): Tyson Farms, Inc. d/b/a River Valley Animal
Foods
c. Person legally responsible for permit: Gregg Wikstrom
First MI Last
Plant Manager
Title
501 Sheffield Road
Permit Holder Mailing Address
Harmony NC 28634-
City State Zip
Page 1 of 2 Revised 7/01/2014

Phone E-mail Address
d. Facility name: Tyson Farms, Inc
e. Facility's physical address: 501 Sheffield Road
Address
Harmony NC 28634-
City State Zip
f. Facility contact person: Kevin Haynes
First MI Last
EHS Manager
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?
® 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 Date
APPLICANT CERTIFICATION
I,Greg Wikstrom,attest that this application for a name/ownership change has been reviewed and is accurate and
complete to o my knowledge. I understand that if all required parts of this application are not completed and that
if all requir po g information is not included,this application package will be returned as incomplete.
Signature Date
**************************
PLEASE SEND THE COMPLETE APPLICATION PACKAGE TO:
Division of Water Resources
NPDES PERMIT NAME/OWNERSHIP CHANGE REQUEST
Page 2 of 2 Revised 7/01/2014

AitA
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 NI'l)ES wastewater permits.
• "Permittee"references the existing permit holder
• "Applicant" references the entity applying for the ownership/name change.
1. NPDES Permit No. (for which the change is requested): N C 0 0 0 5 1 2 6
or
Certificate of Coverage#: N C G 5
H. Existing Permittee Information:
a. Permit issued to(company name): Tyson Foods, Inc d/b/a River Valley Animal Foods
b. Person legally responsible for permit: Gregg Wikstrom
First MI Last
Plant Manager
Title
501 Sheffield Road
Permit Holder Mailing Address
Harmony NC 28634-
City State Zip
[phone] [phone]
Phone Fax
c. Facility name: Tyson Foods, Inc d/b/a River Valley Animal Foods
d. Facility's physical address: 501 Sheffield Road
Address
Harmony NC 28634-
City State Zip
e. Facility contact person: Kevin T Haynes [phone]
First / MI / Last 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
If other please explain: Legal department has advised that it is critical that the proper legal entity
appear on all permits and government correspondence
b. Permit issued to(company name):
Tyson Farms, Inc. d/b/a River Valley Animal
Foods
c. Person legally responsible for permit: Gregg Wikstrom
First MI Last
Plant Manager
Title
501 Sheffield Road
Permit Holder Mailing Address
Harmony NC 28634-
City State Zip
Page t of 2 Revised 7/01/2014

Phone E-mail Address
d. Facility name: Tyson Farms, Inc
e. Facility's physical address: 501 Sheffield Road
Address
Harmony NC 28634-
City State Zip
f. Facility contact person: Kevin Haynes
First MI Last
EHS Manager
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?
® 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 Date
APPLICANT CERTIFICATION
I,Gregg Wikstrom,attest that this application for a name/ownership change has been reviewed and is accurate and
complete to th �, o my knowledge. I understand that if all required parts of this application are not completed and that
if all requir-: • •po, ng information is not included,this application package will be returned as incomplete.
.4004
Signature Date
**************************
PLEASE SEND THE COMPLETE APPLICATION PACKAGE TO:
Division of Water Resources
NPDES PERMIT NAME/OWNERSHIP CHANGE REQUEST
Page 2 of 2 Revised 7/01/2014