NCG060217 - Smithfield Packaged Meats Corp - Wilson

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Division of Energy, Mineral & Land Resources FOR AGENCY USE ONLY
Date Received
(or) Certificate of Coverage
Land Quality Section/Stormwater Permitting Year Month Day
NCDENR
National Pollutant Discharge Elimination System
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PERMIT NAME/OWNERSHIP CHANGE FORM
I. Please enter the permit number for which the change is requested.
NPDES Permit
(or) Certificate of Coverage
N ;C ;S 0 1 1 1 1 11
1 N I ;C I 6 10 1 6 10 2 1 7
R. Permit status prior to requested change.
a. Permit issued to (company name):
Smithfield Farmland Corp. - Wilson Facility
b. Person legally responsible for permit:
Jose E Pabon
First MI Last
RECEIVED
Plant Manager
Title
FEB 0 2Q13
2401 Wilco Blvd
Permit Holder Mailing Address
DENR-LAND QUALITY
Wilson NC 27893
STORMWATER PERMITTING
City State Zip
[phone] [phone]
Phone Fax
c. Facility name (discharge):
Smithfield Farmland Corp. - Wilson Facility
d. Facility address:
2401 Wilco Blvd
Address
Wilson NC 27893
City State Zip
e. Facility contact person:
Kerry B. Strong [phone]
First / MI /Last Phone
III. Please provide the following for the requested change (revised permit).
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:
b. Permit issued to (company name):
Smithfield Packaged Meats Corp -Wilson
c. Person legally responsible for permit:
Jose E Pabon
First MI Last
d. Facility name (discharge):
e. Facility address:
f. Facility contact person:
Plant Manager
Title
2401 Wilco Blvd
Permit Holder Mailing Address
Wilson NC 27893
City State Zip
[phone] [e-mail]
Phone E-mail Address
Smithfield Packaged Meats Corp -Wilson
2401 Wilco Blvd
Address
Wilson NC 27893
City State Zip
Kerry B Strong
First MI Last
[phone] [e-mail]
Phone E-mail Address
IV. Permit contact information (if different from the person legally responsible for the permit)
Revised Jan 27, 2014

NPDES PERMIT NAME/OWNERSHIP CHANGE FORM
Page 2 of 2
Permit contact: Kerry B Strong
First MI Last
Environmental Coordinator
Title
2401 Wilco Blvd
Mailing Address
Wilson NC 27893
City State Zip
[phone] [e-mail]
Phone E-mail Address
V Will the permitted facility continue to conduct the same industrial activities conducted prior
to this ownership or name change?
® Yes
❑ No (please explain)
VI. Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS
ARE INCOMPLETE OR MISSING:
❑ This completed application is required for both name change and/or ownership change
requests.
❑ 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.
The certifications below must be completed and signed by both the permit holder prior to the change, 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, Jose Pabon, 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
red as inco ete
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Signature ` Date
APPLICANT CERTIFICATION
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
PLEASE SEND THE COMPLETE APPLICATION PACKAGE TO:
Division of Energy, Mineral and Land Resources
Stormwater Permitting Program
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
Revised Jan 27, 2014