NCG140179 Ownership Change Form

AA
Division of Energy, Mineral & Land Resources FOR AGENCY USE ONLY
Date Received
r.�...�� Land Quality Section/Stormwater Permitting Year Month Da
�+` National Pollutant Discharge Elimination System
NCDENR
NimMZ ( D .] Or
PERMIT NAMEIOWNERSHIP CHANGE FORM
M f NIC NU �H
EM" -N-- E9
I. Please enter the permit number for which the change is request (�%J��
1 q q
/ q Co
�Certifidate
NPDES Permit
(or) f eg a
,:'IN101 I I I I I
L�j_Ljb'j'.G'j 1 14101 1 0
IL Permit status prior to requested change.
I ---
a. Permit issued to (company name):
Southern Equipment Com an
b, Person legally responsible for permit:
Steve Simonsen
First MI Last
RECEIVEDEnvironmental
Manager
I.._
Title
2 9 2013
3015 Windward Plaza Suite 300
,IAN
Permit Holder Mailing Address
DENR-LAND QUALITY
Alpharetta GA 30005
STORMWATER PENAITT4NG
— City state Zip
[phone] { )
Phone Fax
c. Facility name (discharge):
Ready Mixed Concrete Company - Lumberton, Plant
Lumberton
116
d. Facility address:
201 S Walnut
City
Address
Zip
Lumberon NC 28358
Winnie
City State Zip
e. Facility contact person:
[phone] Ext.
MI
And Sta ch 10290
First / MI / Last Phone
111. Please provide the following for the requested change (revised permit).
a. Request for change is a result of:
® Change in ownership of the facility
❑ Name change of the facility or owner
If other please explain:
b. Permit issued to (company name):
Concrete Service Co. Inc.
c. Person legally responsible for permit:
Richard R Allen
First M1 Last
President
Title
PO Box 1867
Revised Jan, 27, 2014
Permit Holder Mailing Address
Fayetteville
NC _
28302
City
State
Zip
910 483-0396
boballen'r €a block.com
Phone
Eanail Address
d. Facility name (discharge):
Concrete Service - Lumberton_
e. Facility address:
201 S Walnut
Address
Lumberton
NC
28358
City
State
Zip
f. Facility contact person:
Winnie
Jenkins
First
MI
Last
[phone]
313
Revised Jan, 27, 2014

NPDES PERMIT NAMEIOWNERSHIP CHANGE FORM
Page 2 of 2
Phone E-mail Address
IV. Permit contact information (if different from the person legally responsible for the permit)
Permit contact:
First Mi Last
Title
Mailing Address
City State Zip
Phone E-mail Address
V Will the permitted facility continue to conduct the same industrial activities conducted prior
to this ownership or name change?
® Yes
❑ No (please explain)
V1.Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS
ARE INCOMPLETE OR MISSING:
❑ 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 trust 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. 1 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.
Z�f
jF "J"1` ' Signature Date
APPLICANT' CERTIFICATION CAA1-�j
1, Richard R. Alien attest that this application for a name/ownership change has been reviewed and is
accurate and complete to the best of my knowledge. 1 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.
A �� - - w14-)
Signature Date
........................ I...........
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, 20114

This certlFes that PIN: 323802029;323802026;323802027;323804031
Is free of any delinquent ad valorem Tax liens
charged to the Robeson County Tax Collector;
but does certify that the. dead description
I=,
this PIN. �
Z' `�1.1 December M2417
Mapping Technician Signature Date
NORTH CAROLINA SPECIAL
2017010685
ROBESON GQ, NO FEE $2$_00
STATE OF NC REAL ESTATE EXTX
$353.00
PRESENTEE? & RECORDED:
_ 12-18-2017 11:55:10 AM
VICKI Ll-OCKLEAR
_-� REGISTER OF DEEDS
---"'� By; YO i.AND"NV1LLIAMS
DEPu'y
BFC: D 21U
PG: 36.2-367
WARRANTY DEED
I
Excise Tax: $353.00 ! 'Return to.: Wyatt'Early Harris Wheeler, LLP (David
Woods) Po Drawer 2086, High Point, NC 27261.
Parcel Identifiet Nos. 323802029, 323$0:2026, 323802027 and 323.804031
Ma%(Box to: Grantee
This instrument was prepared by: Kilpatrick Townsend & Stockton LLP (BFR){without :title examination)
Brief description for the Index: 201 S.- Walnut Street
�7
THIS DEED made this F-> day of December, 2017, by and between
GRANTOR
Metro Products and Construction, Inc.,
a North Carolina corporation
301 5 "Windward Plaza, Saute 300,
Alpharetta,. GA. 30005
GRANTEE
Allen. of Fayetteville 1, LLC,
a North Carolina limited liability company
103 Builders Blvd
Fayetteville, NC 29301
Enter in appropriate block for each party: name, address, and, if appropriate; character of entity, e.g. corporation or partnership.
The designation Grantor and Grantee as used herein shall include said parties, their heirs, successors, and assigns, and shall
include singular, plural, ,,nnasculine, feini>nine or neuter as required by context,
WITNESSETH, that the Grantor, for a valtrable consideration paid by the Grantee, the receipt of which is hereby
acknowledged, has and bythese presents does grant, bargain, sell and convey unto the Grantee in feesimple, all,that certain
lot or parcel of land situated iii Robeson County, North Carolina and -more particularly described as follows:
SEE EXHIBIT A ATTACHED Iil;12ETO AND INCORPORATED HEREIN BY REFERENCE.
#1--RobtAoll Qowrty
US2008 13665753 2

MEMORANDUM OF LEASE
THIS MEMORANDUM OF LEASE ("Memorandum") is signed as of December 15,
2017, by ALLEN OF FAYETTEVILLE I, LLC, a North Carolina limited liability company,
with its principal offices in Cumberland County, North Carolina ("Landlord"), and
CONCRETE SERVICE CO., INC., a North Carolina corporation, with its principal offices in
Cumberland County, North Carolina ("Tenant").
Landlord and Tenant have entered into a lease ("Lease") dated as of the date of this
Memorandum for valuable consideration with respect to certain "Premises" in the Town of
Lumberton, Robeson County, North Carolina, more fully described and/or depicted on attached
Exhibit A.
The term of the Lease is scheduled to commence on December 15, 2017, and expire on
December 14, 2022, unless sooner terminated as provided in the Lease. Tenant shall have the
five (5) options to extend the term of the Lease for periods of five (5) years each as specified in
the Lease.
This Memorandum is executed for the purpose of giving record notice of the existence of
the Lease for the term provided above. All terms and conditions of the Lease are incorporated
into this Memorandum by reference.
[SIGNATURES APPEAR ON THE FOLLOWING PAGES.]
72147753

Landlord and Tenant have executed this Memorandum as of the date set forth above.
La AT�EN F F YETTEVILLE I, LLC
Name: Richard R. A119 Or.
Title: Manager
Tenant: CONC TE SERVICE CO., INC.
c
Name: ;
Title: 00 r jo
STATE OF NORTH CAIKOUNA JQJ
COUNTY OF Whk
I, the undersigned, a Notary public of the County and State aforesaid, certify that the following person(s)
personallpcared before me this day, and
I V1 T have personal knowledge of the identity of the principal(s)
❑ I have seen satisfactory evidence of the principal's identity, by a current state or federal
identification with the principal's photograph in the form of a
❑ A credible witness has sworn to the identity of the principal(s);
each acknowledging to me that he or she voluntarily signed the foregoing document for the purpose stated
therein and in the ca acity indicated: Richard R. len Jr: ana er t Alle t P'a ettevzlle l LLU.
Date: �- '" i �-fJ I A ) 0. t 1-1V
L9rf��/'®®otary Public
(print name) 1
P ! J
(of
ficial laI) My commission expires:
r
.rPB S �OF NOR CA L A 1
eat°4°�8atpsie� ee TY OF
the undersigned, a Notary Public of the County and State aforesaid, certify that the following person(s)
personallyyappeared before me this day, and
M I have personal knowledge of the identity of the principal(s)
❑ I have seen satisfactory evidence of the principal's identity, by a current state or federal
identification with the principal's photograph in the form of a
❑ A credible witness has sworn to the identity of the principal(s);
each acknowledging to me that he or she voluntarily signed the foregoing document for the purpose
stated therein and in the capacity indicated:: dY{��i fir► (name)
Date:
JI t T f;IllVdtary Public
�ttttt¢�aar�fafiA
�g R F4� �� (print name) ✓� �^' �J jy�/�
4` seal) My commission expires:
M �
0
2
ria `�v
���fFFA �IFIIt3�1�tt;4

EXHIBIT A
STATE OF NORTH CAROLINA
COUNTY OF ROBESON
Tracts 1, 2, 3 and 4 conveyed by Deed from Metro Products and Construction, Inc.,
Grantor, to Allen of Fayetteville 1, LLC, Grantee, dated December 13, 2017, and
recorded on December 18, 2017, in Book 2114, page 362, Robeson County, NC, Public
Registry.
u:laevanslargosllease documentslrobeson countylrobeson county memorandum of lease.docx
3
72147753