NCG020007_Name-Owner Change Form_20180618

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) #:
NCG020007
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: Unimin Corporation
Corrpany Nlarre
b. Person legally responsible for permit:
First name:* Middle name: Last name:*
Douglas S Losee
Title: Vice President of Environmental
Permit holder's mailing address:*
Phone #:*
50738
62111
c. Facility name:*
Fax #:
50736
82110
Street Address
121 St Andrews Court
Address Line 2
oty State / F rovince / Fbgion
Mankato MN
Fbstal / Zip Code Country
56001 United States
Unimin Corp -Marston
d. Facility address:* Street Address
Hwy 177 N
Address Line 2
oty
State / F rovince / Fbgion
Marston
NC
Fbstal / Zip Code
Country
28363
United States
e. Facility contact person (prior to change, optional):
First name: Middle name: Last name:
Matt Wilkins
Phone #: [phone]

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: Covia Holdings Corporation
Corrpany Nacre
c. Person to be legally responsible for permit:
First name:* Middle name: Last name:*
Doug Losee
Title: Vice President of Environmental
Permit holder's mailing address:*
Street Address
121 St Andrews Court
Address Line 2
Oty
Mankato
Rxstal / Zip Code
56001
Phone #:* Email address:*
50738 douglas.l
62111 osee@co
viacorp.c
om
d. Faciltiy name: * Marston Plant
Is the FACILITY contact different than the person legally responsible
above?*
r Yes
f No
f. Facility contact person:
First name:*
Matt
Phone #:*
Middle name:
9105824816
Email address:* [e-mail]
Last name:*
Wilkins
State / Province / Fbgion
MN
Country
United States

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 form the person legally responsible for the perrrit)
..................................................................................................................................................................................................................
First Name:*
Middle Last Name:*
Kris
Name: Benusa
Title:
Environmental Specialist
Mailing Address:*
Street Address
121 St. Andrews Court
Address Line 2
City
Mankato
F bstal / Zip Code
56001
Phone #:* 5073862913
Email Address:* [e-mail]
State / Rovince / Fbgion
MN
Country
United States

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
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 [phone] or e-mail her at [e-mail].

Initial Review
Project ID:* NCG020007