NCG060031_Permit Owner Affiliation Change_20180320

ROY COOPER
MICHAEL S. REGAN
LINDA CULPEPPER
Wafer Resources t""^", °i"",'•
ENVIRONMENTAL QUALITY
PERMIT NAME/OWNERSHIP CHANGE FORM
CURRENT PERMIT INFORMATION
Permit Number: NCG060031
1. Facility Name: ADM Southport
II. NEW OWNER/NAME INFORMATION:
1. This request for a name change is a result of:
_a. Change in ownership of property/company
_X—b. Name change only
_c. Other (please explain):
2. New owner's name (name to be put on permit)
Tara E.Tolly
3. New owner's or signing official's name and title: Tara E. Tolle
(Person legally responsible for permit)
Plant Mnnacer
(Title)
4. Mailing address: 1730 East Moore Street SE City: Southport
State: NC Zip Code: 28461 Phone: [phone]
E-mail address: Tara.Tollv(e.ADM.com
THIS APPLICATION PACKAGE WILL NOT BE ACCEPTED BY THE DIVISION UNLESS ALL OF THE
APPLICABLE ITEMS LISTED BELOW ARE INCLUDED WITH THE SUBMITTAL.
REQUIRED ITEMS:
1. This completed application form
2. Legal documentation of the transfer of ownership (such as a property deed, articles of
incorporation, or sales agreement)
[see reverse side of this page for signature requirements]
State of North Carolina I Environmental Quality I water Resources
1617 Mail Service Center I Raleigh, NC 27699-1617
9198076300 919-807-6389 FAX
https://deq.nc.gov/about/divisions/water-resources/wa(er-resources-permits/wastewater-brmch/npdes.wastewater-permits

NPDES Name & Ownership Change
Page 2 of 2
Applicant's Certification:
I, Tara E. Tolle , 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 and attachments are not included, this application
package will be returned as incomplete.
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Signature: Date: March 15, 2018
THE COMPLETED APPLICATION PACKA�E, INCLUDING ALL SUPPORTING
INFORMATION & MATERIALS, SHOULD BE SENT TO THE FOLLOWING ADDDRESS:
INC DEQ i DWR / NPDES
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Version 11/2017