NCG070146_Name-Ownership Change Request_4/12/2018 (2)

NPDES Permit Name/Ownership Change Request
I. Permit In formation
NPDES Stormwate r Indiv idual Pe rmit #:
- OR -
Ge ne ral Pe rmit Ce rtificate of Cov e rage (COC) #:
Use this link to check the permit contact information that is currently in our database.
I. Please enter the permit number for which the change is requested.
NC
SX
XX
XX
X
NCG070146
NC
GX
XX
XX
X
II. Permit Status
a. Pe rmit issue d to:*
b. Pe rson le gally re sponsible for pe rmit:
First name :*M iddle name :Last name :*
Title :
Pe rmit holde r's mailing addre ss:*
Phone #:*Fax #:
c. Facility name :*
d. Facility addre ss:*
e . Facility contact pe rson (prior to change , optional):
First name :M iddle name :Last name :
Phone #:
II. Permit status prior to requested change.
Kings Mountain Mining, Inc.
Company Name
Peter Flynn
City
Kings Mountain
State / Province / Region
nc
Postal / Zip Code
28086
Country
USA
Street Address
PO Box 1668
Address Line 2
704-
734-
3515
704-
739-
3713
Kings Mountain Mining, Inc.- Battleground
City
Kings Mountain
State / Province / Region
NC
Postal / Zip Code
28086
Country
US
Street Address
1214 South Battleground Avenue
Address Line 2
Peter Flynn
704-734-3515
III. Req u ested Chan g e In formation
a. Re que st for change s is a re sult
of:*
b. Pe rmit to be issue d to:*
c. Pe rson to be le gally re sponsible for pe rmit:
First name :*M iddle name :Last name :*
Title :
Pe rmit holde r's mailing addre ss:*
Phone #:*Email addre ss:*
d. Faciltiy name :*
Is the FACILITY contact diffe re nt than the pe rson le gally re sponsible
abov e ?*
f. Facility contact pe rson:
First name :*M iddle name :Last name :*
Phone #:*
Email addre ss:*
III. Please provide the following for the requested change (revised permit).
Change in ownership of facility
Name Change of the facility or owner
Imerys Mica Kings Mountain, Inc.
Company Name
Joel Ventura
Operations Manager
City
Kings Mountain
State / Province / Region
NC
Postal / Zip Code
28086
Country
USA
Street Address
P.O. Box 1668
Address Line 2
450-
655-
2450
joel.vent
ura@ime
rys.com
Battleground
Yes
No
Michael Henders
on
704-477-8105
[e-mail]
IV. Permit Contact Information
Is the PERM IT contact diffe re nt than the pe rson le gally re sponsible
abov e ?*
First Name :*M iddle
Name :
Last Name :*
Title :
M ailing Addre ss:*
Phone #:*
Email Addre ss:*
Yes
No
IV. Permit contact information
(if different form the person legally responsible for the permit)
Michael Henders
on
Production Manager
City
Kings Mountain
State / Province / Region
NC
Postal / Zip Code
28086
Country
USA
Street Address
P.O. Box 1668
Address Line 2
7044778105
[e-mail]
V. Permit Facil ity Activities
V. Will the pe rmitte d facility continue to conduct the SAM E industrial activ itie s conducte d prior to this
owne rship or name change :*
Yes
No
VI. Sig n atu re
In the case of an owne rship change re que st, signe d ce rtifications must be comple te d by both the
pe rmit holde r prior to the change and the ne w applicant. For a name change re que st, the signe d
Pe rmitte e 's Ce rtification is sufficie nt.
This comple te d application is re quire d for both name change and/or owne rship change re que sts.
Signe d Ce rtification Upload *
See the Permittee Certification and (if applicable) Applicant Certification for completion and upload above.
Will another person need to complete this form or upload a signed certification before it can be submitted? No
problem! Simply CLICK the "Save as Draft" button below and send the URL link to the other party to access the form.
Que stions? Call Laura Alexander at [phone] or e-mail her at [e-mail].
A signed certification statement is required
Battleground Applicant Certification Joel
Ventura Executed.pdf
378.89KB
pdf only