NCG130041 - Raleigh C&D Processing Facility

Division of Water Quality / Surface Water Protection FOR AGENCY USE ONLY
1 • Date Received
Year Month Day
National Pollutant Discharge Elimination System
NCDENR
ROMMeM aR PERMIT NAME/OWNERSHIP CHANGE FORM
ENVIppNMEN{AND N.OlkiAl. RE�OLJgCE9
I. Please enter the permit number for which the change is requested.
NPDES Permit
(or) Certificate of Coverage
N ;C S, QN
C G 1 3 0 0 T4]T]
H. Permit status prior to requested change.
a. Pernut issued to (company name):
WCA of North Carolina LLC
b. Person legally responsible for permit:
Jaun Carroll
First MI Last
Operations Manager
Title
421 Raleigh View Road
Permit Holder Mailing Address
Raleigh NC 27610
City State Zip
[phone] ( )
Phone Fax
c. Facility name (discharge):
Material Reclamation, LLC
d. Facility address:
421 Raleigh View Road
Address
Raleigh NC 27610
City State Zip
e. Facility contact person:
Christopher T Roof ( 919) 201-1434
First / MI /Last Phone
lII. 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
Revised 2012Apr23
If other please explain:
b. Pernut issued to (company name):
c. Person legally responsible for permit:
ake Reclamation LLC
Donald Plessinger
First MI Last
Facility Manager
Title
421 Raleigh View Road
Pertmt Holder Mailing Address
Raleigh NC 27610
City State Zip
(919)201-1(434,)[e-mail]
Phone E-mail Address
d. Facility name (discharge): Ralei h C&D Processinq Facility
e. Facility address: 421 Raleigh View Road
Address
Raleigh NC 27610
City State Zip
f. Facility contact person: Donald Plessinger
First MI Last
( ) SAME AS ABOVE
Phone E-mail Address UZ
W

NPDES PERMIT NAME/OWNERSHIP CHANGE FORM
Page 2 of 2
IV. Permit contact information (if different from the person legally responsible for the permit)
Permit contact: John -C. Pf leper
First MI Last
Sr. EHS Specialist
Title
/ 3301 Benson Drive, Suite 601
✓ Mailing Address
Raleiqh NC 27609
City State Zip
(919)20173033)[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?
❑x Yes
❑ No (please explain)
VI. Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS
ARE INCOMPLETE OR MISSING:
Q This completed application is required for both name change and/or ownership change
requests.
Q 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, , 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 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 Water Quality
Surface Water Protection Section
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Revised 7/2008