NCG110069_Permit Contact Update_20180228

Divisionof1Jnergy, Mineral & Land Resources
Land Quality Section/Sto•mwater Permitting
National pollutant Discharge Elimination System
PERMIT NAME/OWNERSHIP CHANGE FORM
Please enter the permit number for which the change is requested.
NPDES Permit (Or)
tu
II. Pei
in stas ,into to requested change.
a. Permit issued to (company name):
b. Person legally responsible for permit:
R A
FOGENCY USE ONLY
Date Received
Year
Month
Day
Certificate of Coveraee
(JingDx� t�r�� r i
. L� ("w tz
Past MI Last
Title
v
Permit Holder Mailing Address
City State Zip
Phone Fax
d. Facility address: Ute, r> £. � LA/ic
% Address
City State Zip
e. Facilitycontactperson: i2A 5,
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
Ifotherplease eiplain: C i-jAejC�. e>r t L
b. Permit issued to (company name): t~.x,t_;� t c may.LxL;� C s
c. Person legally responsible for permit: "V(4 r- v1t t
Fr st TH Last
1 GC: d \vc tS:U-`ic
d. Facility name (discharge):
e. Facility address:
f. Facility contact person:
Title
Pemrit Holder Mailing Address
-p City State Zip
C`n
Plrone E -nail Address
City State Zip
C -
First g/ MI Last
((
Phone
E-mail Address
IV. Permit contact information (if different fi•om the person legally responsible for the permit)
Revised Jan. 27, 2014

NPDES PERMIT NAME/OWNERSHIP CHANGE FORM
Page 2 of 2
Permit contact:
First h41 Last
Title
Mailing Address
( City t!(64State Zip
-�`ee 4( :Pz,` c4i ie. e W`.CLtc. C=%
Phone E-mail Address
V Will the permitted facility continue to conduct the same industrial activities conducted prior
to tills ownership or nanne change?
Ky. Yes
❑ No (please explain)
VI. Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS
ARE, INCOMPLETE OR MISSING:
f This completed application is required for both name change and/o• 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 fo• 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, , 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, , attest that this application for a nanne/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
Storrmwater Permitting Program
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
ReHsed Jan. 27, 2014