NCG070118_Owner Name Change Review Form_4/12/2018

Environmental
Quakry
I. Permit Information
I. Please enter the permit number for which the change is requested.
NPDES Stormwater Individual Permit #:
NC
SX
XX
XX
X
-OR-
General Permit Certificate of Coverage (COC) #:
ncg070118
NC
GX
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: Rinker Materials -Wilson Pipe
Corrpany Nlarre
b. Person legally responsible for permit:
First name: Middle name
Dave
Title:
Permit holder's mailing address:
Phone #:
252-
243-
6153
Ext
201
c. Facility name:
d. Facility address:
Fax #:
Last name:
Clifford
Street Address
1600 Thorne Ave
Address Line 2
City
State / Province / Fbgion
Wilson
NC
Fbstal / Zip Code
Country
27893
USA
Rinker Materials -Wilson Pipe
Street Address
1600 Thorne Ave
Address Line 2
aty
State / Province / Fbgion
Wilson
NC
Fbstal / Zip Code
Country
27893
USA
e. Facility contact person (prior to change, optional):
First name: Middle name: Last name:
John Davis
Phone #: [phone] Ext. 208

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: Rinker Materials -Wilson Pipe
Company �Jarre
c. Person to be legally responsible for permit:
First name: Middle name: Last name:
Keith Cronin
Title: Production Manager
Permit holder's mailing address:
Phone #
252-
243-
6153
d. Faciltiy name:
Email address:
keithp.cr
onin@rin
kerpipe.c
om
Street Address
1600 Thorne Ave
Address Line 2
oty
Wilson
Fbstal / Zip Code
27893
Rinker Materials -Wilson Pipe
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:
Robert Stricklan
d
Phone #: [phone]
Email address: [e-mail]
State / Province / Pegion
NC
Country
USA

IV. Permit Contact Information
Is the PERMIT contact different than the person legally responsible
above?
f Yes
r No

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
New Document1.pdf 745.04KB
pdt only

Initial Review
Project ID: * ncg070118