NCG050017 - Berry Global, Inc.

-it
T ' Division of Energy, Mineral & Land Resources FOR AGENCY USE ONLY
1 • o Date Received
��,�.�!_ Land Quality Section/Stormwater Permitting Year I Month Day
NC®ENR National Pollutant Discharge Elimination System
No- Grm Derurrnrxr of
Etmrtonm-- N- Resources PERMIT NAME/OWNERSHIP CHANGE FORM
I. Please enter the permit number for which the change is requested.
IV. Permit contact information (if different from the person legally responsible for the permit) ,n
Revised Jan. 27, 2014 W//„�W�!,!ff �h'�n/�
1 .K A J 1 h.Y lYY 1
NPDES Permit
(or) Certificate of Coverage
N
,C; S, 10, 1 1 1
1 N I C G p $ 0 0 117
II. Permit status prior to requested change.
Permit issued to
e q j +j C's
a.
(company name):
R'` y
b.
Person legally responsible for permit:
C-, Ct 2R u W Q1tWt%R
Firsf MI Last
1 ctrv1 Rar-, 0,q e �
RECEIVE®
Title
na s Tok nomy K Jael 12d
Permit Ho der Mailing Address
MAR 061010
R has kre__ N�- �79/O
City State Zip
DENR-LAND QUALITY
(.M ) 33D- 7 A(o 9 ( �53- ) 33,2 - J3_17
STORMWATER PERMITTING
Phone Fax
c.
Facility name (discharge):
ll
, 7 I C 9 r i e 3
d.
Facility address:
2 oZ n Zo L\ ]nom,► 1'� + V 0\211 12C
Address
Rho 5 k1 P-- /U 0110
e.
Facility contact person:
Ci State Zip
M ; 17 �I eP h Q R� ( a5a) 3
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
M Name change of the facility or owner
If other please explain:
b.
Permit issued to (company name):
f -P R \l InbalIN c
c.
Person legally responsible for permit:C
C< RRy U-9nQ.�,efZ
MI Last
`Firs ` j
\ w-, �-1 Q A7 Q,Q e, JK
Title
Dag o%nn\ R" �C' 2oI Q j
Permit H lder Mailing Address
Rhoskfe AJ G 0910
City State ZIP
(a5�) 339-`7a0 arta, bake2 e-� ol�a(. cant
Phone 10 E-mail Address
d.
Facility name (discharge):
L C
e.
Facility address:
kI i e I I
Address
(�h 09111 MC �'7 9 I
f.
Facility contact person:
City State `Zip
f i f Z I �efV 1) �i IP
Fir9t MI Last
casa) �.�a� � a$ � rn►+z�� b�eNhaz+ � be2�z,��lo bal��o"1
Phone E-mail Address
IV. Permit contact information (if different from the person legally responsible for the permit) ,n
Revised Jan. 27, 2014 W//„�W�!,!ff �h'�n/�
1 .K A J 1 h.Y lYY 1

NPDES PERMIT NAME/OWNERSHIP CHANGE FORM
Page 2 of 2
Permit contact: i 7�l BC.d,J ha Q +
—First MI Last
�Off17\�arC,Q- fi'1L'(NQQ el -Fl -
Title
Baa jokhf-1 / M-.601 VCI
Mailing Address
G�hoS�� NC, 19'7910
City State Zip
o5a )3.3D -7x88 )Ly b erlloRz ebeRi--7,(alobalo (opl
Phone -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)
ViRequired Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS
ARE INCOMPLETE OR MISSING: -
J9 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, , 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
ARPLIC j CF TIFICATION
a est tLt 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 that if all r su r information is not included, this application package will be
returned as ncomplete
11 -1-) 3 1f
Signature bate
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