NC0006190_Legally Responsible for Permit_20160824

Excel Civil
& Environmental Associates,
625 Huntsman Court
Gastonia, North Carolina 28054
NC License No. P-0129
Telephone: [phone]
Facsimile: [phone]
Int -et: www.exceleng-- p^
F.EGEIU , fEI)INCDEUI U�Y f\ ,j�e
PLLC
August 19, 2016
NCDEQ/ DWR
Water Quality Permitting Section
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Re: Change in Ownership for
Delta Apparel to South Fork Industries
NPDES Permit No. NC0006190
Attached please find the following items related to the enclosed application:
• Ownership Change Request for NC0006190; and
• Transfer of Ownership Documentation.
AUG 2 4 2016
Water Quality
Permitting
Please feel free to contact me with additional questions regarding the application.
Sincerely yours,
EXCEL CIVIL & ENVIRONMENTAL ASSOCIATES, PLLC
Michael Sta or h, PE
Principal Engineer
EXCEL CIVIL & ENVIRONMENTAL ASSOCIATES, PLLC
I 1, 1-e(r ',\ -
c _ wwvir:excelengr-com�=�I

NC®EN
North Carolina Department of Environment and Natural Resources
Division of Water Resources
Pat McCrory
Governor WATER QUALITY PERMITTING SECTION
John E. Skvarla, III
Secretary
PERMIT NAME/OWNERSHIP CHANGE REQUEST
This form is for ownership changes or name changes of NPDES wastewater permits.
o "Permittee" references the existing permit holder
"Applicant" references the entity applying for the ownership/name change.
L NPDES Permit No. (for which the change is requester): � N C 0 0 6 1 9 0
or
Certificate of Coverage #: N C G 5
H. Existing Permittee Information:
a. Permit issued to (company name): Delta Apparel, Inc.
b. Person legally responsible for permit: Steven Slaughter
First Ml Last
RECEIVEDINCDEUDWR Plant Manager
Title
AUG 2 4 2016 100 West Pine Street
Permit Holder Mailing Address
Water Quality Maiden NC 28650-
Rerrnitting Section City State Zip
[phone] ( )
Phone Fax
c. Facility name: Delta Apparel, Inc.
d. Facility's physical address: 100 West Pine Street
Address
Maiden NC 28650 -
City State Zip
e. Facility contact person: Steven Slaughter [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
!f other please evplain:
b. Permit issued to (company name):
c. Person legally responsible for permit:
South Fork Industries, Inc.
Everette Owens
First MI Last
Plant Manager
Title
PO Box 1220
Permit Holder Mailing Address
Lincolnton NC 28093 -
City State Zip
[phone] everettet�r�rsouthforkind.com
Phone E-mail Address
Page 1 ort Revised 7/01/2014

d. Facility name:
c. Facility's physical address:
f. Facility contact person:
South Fork Industries, Inc. - Maiden Plant
100 West Pine Street
Address
Maiden NC 28650
City State Zip
Everette Owens
First MI Last
Plant Manager
Title
[phone] everette asouthforkind.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 perniit 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 decd, 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
.....................................................................................I......11.......11..............
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, Steve Slauehtcr for Delta Apparel, Inc., 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.
S -nature Date
APPLICANT CERTIFICATION
I, Everette Owens for South Fork Industries, Inc., 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 pacicagc will be returned as
incomplete.
Signature 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 7/01/2014