NCG060014_Name Ownership Change Request_4/10/2018

Environmental
Quakry
I. Permit Information
I. Please enter the permit number for which the change is requested.
NPDES Stormwater Individual Permit #:
ncg060014
NC
sx
xx
xx
x
-OR-
General Permit Certificate of Coverage (COC) #:
NC
CDC
xx
xx
x
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: Ajinomoto North America, Inc.
Conpany Nine
b. Person legally responsible for permit:
First name: Middle name: Last name:
Mike J Lish
Title: Vice President of Operations
Permit holder's mailing address: street Address
4020 Ajinomoto Drive
Address Line 2
City State / Province / Fbgion
Raleigh NC
Fbstal / Zip Code Country
27610-2911 us
Phone #:
919-
723-
2106
c. Facility name:
d. Facility address:
Fax #:
Ajinomoto North America, Inc.
Street Address
4020 Ajinomoto Drive
Address Line 2
City
State / Province / Fbgion
Raleigh
NC
Fbstal / Zip Code
Country
27610-2911
us
e. Facility contact person (prior to change, optional):
First name: Middle name: Last name:
Jason D. Letchwor
th
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: Ajinomoto Health & Nutrition North America, Inc.
Company Nlarre
c. Person to be legally responsible for permit:
First name: Middle name: Last name:
Mike J Lish
Title: Vice President of Operations
Permit holder's mailing address: Street Address
4020 Ajinomoto Drive
Address Line 2
aty
State / F rovince / Fbgion
Raleigh
NC
Fbstal / Zip Code
Country
27610-2911
us
Phone #: Email address:
919- LishM@a
723- jiusa.com
2106
d. Faciltiy name: Ajinomoto Health & Nutrition North America, 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:
Jason D. Letchwor
th
Phone #: [phone]
Email address: [e-mail]

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
Jason
Title:
Mailing Address:
Phone #
Middle Last Name:
Name: Letchwor
D. th
919-723-2140
EHS Engineer
Street Address
4020 Ajinomoto Drive
Address Line 2
City
Raleigh
F bstal / Zip Code
27610-2911
Email Address: [e-mail]
State / Rovince / Fbgion
NC
Country
us

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
Name Change Blank form.pdf 65.43KB
pdf only

Initial Review
Project ID: * ncg060014