NCG050110_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) #:
NCG050110
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: LLFIex, LLC
Corrpany f brre
b. Person legally responsible for permit:
First name:* Middle name:
Last name:*
220 E. Polo Road
William
Whalen
Title:
Chief Financial Officer
Winston-Salem
Permit holder's mailing address:*
Street Address
Country
27105
220 Polo Road
Address Line 2
oty
State / Province / Fbgion
Winston-Salem
NC
Fbstal / Zip Code
Country
27105
USA
Phone #:*
336- 336-
777- 777-
5800 5126
c. Facility name:*
Fax #:
LLFIex, LLC
d. Facility address:* Street Address
220 E. Polo Road
Address Line 2
oty
State / Province / Fbgion
Winston-Salem
NC
Fbstal / Zip Code
Country
27105
USA
e. Facility contact person (prior to change, optional):
First name: Middle name: Last name:
Benjamin Hutchens
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: Tri -Seal Opco, LLC
Corrpany Wre
c. Person to be legally responsible for permit:
First name:* Middle name: Last name:*
David Waksma
n
Title: Chief Legal Officer, Senior Vice President, Secretary
Permit holder's mailing address:* Street Address
220 Polo Road
Address Line 2
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:*
Benjamin Hutchens
Phone #:* 336-777-4279
Email address:* [e-mail]
aty
State / Province / Plegion
Winston-Salem
NC
Postal / Zip Code
Country
27105
USA
Phone #:*
Email address:*
484-
David. W
831-
aksman
3426
@tekni-
plex.com
d. Faciltiy name:*
Tri -Seal Opco, LLC
e. Facility address:*
Street Address
220 E. Polo Road
Address Line 2
aty
State / Province / Fbgion
Winston-Salem
NC
Postal / Zip Code
Country
27105
USA
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:*
Benjamin Hutchens
Phone #:* 336-777-4279
Email address:* [e-mail]

IV. Permit Contact Information
Is the PERMIT contact different than the person legally responsible
above?*
f• Yes
r No
IV. Permit contact information
(if different form the person legally responsible for the permt)
....................................................................................................................................................................................................
First Name:*
Middle Last Name:*
Benjamin
Name: Hutchens
Title:
Plant Manager
Mailing Address:*
Street Address
220 Polo Road
Address Line 2
City
Winston-Salem
Fbstal / Zip Code
27105
Phone #:* 336-777-4279
Email Address:* [e-mail]
State / Province / Fbgion
NC
Country
USA

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.
Legal documentation of 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.
File Upload:* Upload supporting docurrentation for ownership change
Project Opal - Polo_ Assignment and
4.08MB
Assumption of Lease.PDF
pdf only
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
rtlrtv�r �r&
FL-rrrit-holder prior to the ow nership change, or perrrit-holder authorizing the nave change
Applicant 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.
Applicant Signature
To w horn the pernit is to be transferred
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:* NCG050110