NCG070055_Owner Name Change Form_4/10/2018

Environmental
Quakry
I. Permit Information
I. Please enter the permit number for which the change is requested.
NPDES Stormwater Individual Permit #:
ncg070055
NC
sx
xx
xx
x
-OR-
General Permit Certificate of Coverage (COC) #:
Use this link to check the permit contact information that is currently in our database.

II. Permit Status
11. Permit status prior to requested change.
a. Permit issued to: DUCO-SCI Inc
Companyfbne
b. Person legally responsible for permit:
First name: Middle name: Last name:
Michael Crytzer
Title: VP Engineering
Permit holder's mailing address: Street Address
155 S Rebecca St
Address Line 2
PO Box 568
aty State / Rovince / Pegion
Saxonburg Pennsylvania
Fbstal / Zip Code Country
16056 United States
Phone #:
72435
21511
c. Facility name:
Fax #:
DUCO-SCI Inc
d. Facility address: Street Address
6004 Stitt St
Address Line 2
aty
State / Rovince / Fbgion
Monroe
NC
Fbstal / Zip Code
Country
28110
United States
e. Facility contact person (prior to change, optional):
First name: Middle name: Last name:
Doug Hypes
Phone #: [phone]

III. Requested Change Information
111. Please provide the following for the requested change (revised permit).
a. Request for changes is a result of: r Change in ownership of facility
r Name Change of the facility or owner
b. Permit to be issued to: DUCO-SCI Inc
Company Nlarre
c. Person to be legally responsible for permit:
First name: Middle name: Last name:
Michael Crytzer
Title: VP Engineering
Permit holder's mailing address:
Phone #
72435
21511
d. Faciltiy name:
Email address:
mcrytzer
@du-
co.com
Street Address
155 S Rebecca St
Address Line 2
PO Box 568
City
Saxonburg
Pbstal / Zip Code
16056
DUCO-SCI Inc.
Is the FACILITY contact different than the person legally responsible
above?
r Yes
r No
f. Facility contact person:
First name: Middle name: Last name:
Doug Hypes
Phone #: [phone]
Email address: [e-mail]
State / Province / Fbgion
PA
Country
United States

IV. Permit Contact Information
Is the PERMIT contact different than the person legally responsible
above?
r Yes
r No
IV. Permit contact information
(if different formthe person legallyresponsible for the
.................................................................................................................................
First Name: Middle Last Name:
Doug Name: Hypes
Title: Plant Manager
Mailing Address: Street Address
6004 Stitt St
Address Line 2
aty State / Rovince / Fbgion
Monroe NC
F bstal / Zip Code Country
28110 United States
Phone #: [phone]
Email Address: [e-mail]

V. Permit Facility Activities
V. Will the permitted facility continue to conduct the SAME industrial activities conducted prior to this
ownership or name change:
r Yes
r No

VI. Signature
In the case of an ownership change request, signed certifications must be completed by both the
permit holder prior to the change and the new applicant. For a name change request, the signed
Permittee's Certification is sufficient.
This completed application is required for both name change and/or ownership change requests.
Signed Certification Upload A signed certification staterrent is required
NC PermitSignature Form. pdf 56.5KB
pdt only

Initial Review
Project ID: * ncg070055