NCG020795_Name-Owner Change Form_6/22/2018

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) #:
NCG020795
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
Company tarre
b. Person legally responsible for permit:
First name:* Middle name
Richard M
Title:
Permit holder's mailing address:*
Phone #:*
20396
68880
c. Facility name:*
d. Facility address:*
Fax #:
20396
61977
Last name:*
Solazzo
Street Address
258 Elm Street
Address Line 2
aty
New Canaan
Fbstal / Zip Code
06840
State / Province / Fbgion
CT
Country
United States
Unimin Corporation Schoolhouse Quartz Facility
Street Address
107 Harris Mining Company Rd.
Address Line 2
aty
State / Province / Fbegion
Spruce Pine
NC
Fbstal / Zip Code
Country
28777
US
e. Facility contact person (prior to change, optional):
First name:
Phone #:
Middle name: Last name:

III. Requested Change Information
III. Please provide the following for the requested change (revised permit).
a. Request for changes is a result F Change in ownership of facility
of: * r Name Change of the facility or owner
b. Permit to be issued to:* Sibelco North America
Coapany f Jarre
c. Person to be legally responsible for permit:
First name:* Middle name: Last name:*
Douglas Myers
Title: Regional General Manager
Permit holder's mailing address:* Street Address
Phone #:*
82876
54283
d. Faciltiyname:*
e. FaciIityadd ress:
*
Po Box 588
Address Line 2
City State / Province / legion
Spruce Pine NC
Fbstal / Zip Code Country
28777 United States
Email address:*
Doug.My
ers@sibe
Ico.com
Sibelco North America - Schoolhouse Quartz Facility
Street Address
107 Harris Mining Company Rd.
Address Line 2
City
State / Province / legion
Spruce Pine
NC
Fbstal / Zip Code
Country
28777
US
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:*
Steve Wilson
Phone #:* 8287654251
Email address:* [e-mail]

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 permt)
............................................................................................................................................................................
First Name:* Middle Last Name:*
Jeffrey Name: Ferguso
n
Title: Sr. Environmental Engineer
Mailing Address:* Street Address
136 Crystal Drive
Address Line 2
City
Spruce Pine
Fbstal / Zip Code
28777
Phone #:* 8287651114
Email Address:* [e-mail]
State / Rovince / Fbgion
NC
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.
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 docurrentationfor ownership change
Certificate of Incorporation - Sibelco
727.88KB
North America Inc.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
070�,F 141W
Perrrit-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 perp it 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:* NCG020795