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HomeMy WebLinkAboutNCGNE0253_Name-Owner Change Form_5/9/2018Environmental 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) #: NCGNE0253 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: Pharmalabel Conpany tarre b. Person legally responsible for permit: First name:* Middle name: Last name:* David Murphy Title: General Manager Permit holder's mailing address:* Phone #:* 88885 57142 c. Facility name:* d. Facility address:* Fax #: Street Address 7915 Industrial Village Rd Address Line 2 City State / Province / Fbgion Greensboro NC Fbstal / Zip Code Country 27409-9691 us Pharmalabel Street Address 7915 Industrial Village Rd Address Line 2 City State / Province / Fbgion Greensboro NC Fbstal / Zip Code Country 27409-9691 us e. Facility contact person (prior to change, optional): First name: Phone #: Middle name: Last name: III. Requested Change Information 111. Please provide the following for the requested change (revised permit). a. Request for changes is a result r Change in ownership of facility of: * r Name Change of the facility or owner b. Permit to be issued to: MPS Greensboro, LLC Company l\brre c. Person to be legally responsible for permit: First name:* Middle name: Last name:* Brian Richard Conroy Title: General Manager Permit holder's mailing address:* Street Address 7915 Industrial Village Road Address Line 2 Oty Greensboro Postal / Zip Code 27409-9691 Phone #:* Email address:* 33654 brian.con 45560 roy@wes trock- mps.com d. Faciltiy name:* MPS Greensboro, LLC Is the FACILITY contact different than the person legally responsible above?* r Yes r No State / Province / Pegion NC Country us 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, certifications must be signed 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. North Carolina General Statute 143 - 215.6 b (i) provides that: Any person who knowingly makes any false statement, representation, or certification in any application, record, report, plan, or other document filed or required to be maintained under this Article or a rule implementing this Article; or who knowingly makes a false statement of a material fact in a rulemaking proceeding or contested case under this Article; or who falsifies, tampers with, or knowingly renders inaccurate any recording or monitoring device or method required to be operated or maintained under this Article or rules of the [Environmental Management] Commission implementing this Article shall be guilty of a Class 2 misdemeanor which may include a fine not to exceed ten thousand dollars ($10,000). Permittee Certification: I attest that this application for a name and/or ownership change has been reviewed and is accurate and complete to the best of my knowledge. I understand that if all required parts of this application are not completed, or if all required supporting information is not included, this application will be considered incomplete. Permittee Signature "D MW FLrrrit-holder prior to the ownership change, or permt-holder authorizing the narre change Will another person need to complete or sign this form 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. Questions? Call Laura Alexander at (919) 807-6368 or e-mail her at laura.alexander@ncdenr.gov. Initial Review Project ID:* NCGNE0253