NCG100040_Name-Owner Change Form_20171108

Division of Energy, Mineral & Land Resources FOR AGENCY USE ONLY
• Date Received
1
A� Land Quality Section/Stormwater Permitting Year Month I Day
National Pollutant Discharge Elimination System
NCDENR l
Naomi C- ­DEPARTMENT or
ENVIRONMENT AND.N mURAL RESOURCES PERMIT NAME/OWNERSHIP CHANGE FORM I{
I. Please enter the permit number for which the change is requested.
NPDES Permit
(or) Certificate of Coverage
N C I S 0
C 1G 10 40
II. Permit status prior to requested change.
MI Last
a. Permit issued to (company name):
LKQ Salisbury Inc
b. Person legally responsible for permit:
Title
1212 Webb Rd
First MI Last
Title
Salisbury
1212 Webb Rd
7,!� ❑ a yl,
V
Permit Holder Mailing Address
[phone]
Salisbury NC 28146
p
8 2017
City State Zip
LKQ Salisbury
P,ENF�_LAPiD QUALITY
Phone Fax
gcI''1i�' ITC -R PERI,rlIT.FIP G
Address
c. actlity name (dtsc arge):
LKQ Salisbury Inc
d. Facility address:
1212 Webb Rd
Chuck
Address
Salisbury NC 28146
City State Zip
e. Facility contact person:
Mike Lahr [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
❑m Name change of the facility or owner
If other please explain:
b. Permit issued to (company name):
c. Person legally responsible for permit
C�lll'L1`7Y
d. Facility name (discharge)
e. Facility address:
f. Facility contact person:
LKQ Southeast Inc
Chuck
D Brown
First
MI Last
Plant Manager
Title
1212 Webb Rd
Permit Holder Mailing Address
Salisbury
NC 28146
City
State Zip
[phone]
cdbrown@lkgcorp com
Phone
E-mail Address
LKQ Salisbury
1212 Webb Rd
Address
Salisbury
NC 28146
City
State Zip
Chuck
D Brown
First MI Last
[phone] cdbrown@Ikgcorp com
Phone E-mail Address
IV. Permit contact information (if different from the person legally responsible for the permit)
Revised Jan 27, 2014

-- , r
NPDES PERMIT NAME/OWNERSHIP CHANGE FORM
Page 2 of 2
Permit contact: Chuck D Brown
First MI Last
Plant Manager
Title
1212 Webb Rd
Mailing Address
Salisbury NC 28146
City State Zip
[phone] cdbrown@lkgcorp corn
Phone E-mail Address
V Will the permitted facility continue to conduct the same industrial activities conducted prior
to this ownership or name change?
❑Q 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.
❑ 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
1, CDB , 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.
40- 31- I'j
Signatur Date
7
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