NCG210384_Name-Owner Change Form_6/28/2018

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) #:
NCG210384
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: PalletOne of NC Inc
Conpany�Jane
b. Person legally responsible for permit:
First name:* Middle name: Last name:*
Brian Dyson
Title:
Permit holder's mailing address:*
Phone #:*
336-
492-
5565
c. Facility name:*
d. Facility address:*
Fax #:
Street Address
165 Turkey Foot Road
Address Line 2
aty
State / Rovince / Fbgion
Mocksville
NC
Fbstal / Zip Code
Country
27028
us
Industrial Recycling Services
Street Address
2815 Woodtech Drive
Address Line 2
aty
State / Rovince / Fbgion
Newton
NC
Fbstal / Zip Code
Country
28658
us
e. Facility contact person (prior to change, optional):
First name: Middle name: Last name:
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: Industrial Recycling Services
Conpany %rre
c. Person to be legally responsible for permit:
First name:* Middle name
Larry
Title:
Permit holder's mailing address:*
Last name:*
Draughn
Street Address
165 Turkeyfoot Road
Address Line 2
City
Mocksville
Rbstal / Zip Code
27028
Phone #:* Email address:*
336- Idraughn
492- @palleto
5565 ne.com
d. Faciltiy name:* Industrial Recycling Services
Is the FACILITY contact different than the person legally responsible
above?*
r Yes
f No
f. Facility contact person:
First name:*
BJ
Phone #:*
Middle name
704-462-1882
Email address:* [e-mail]
Last name:*
Kirby
State / Province / Plegion
NC
Country
USA

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:*
BJ Name: Kirby
Title:
Mailing Address:* Street Address
2815 Woodtech Drive
Address Line 2
aty
Newton
Fbstal / Zip Code
28658
Phone #:* 704-462-1882
Email Address:* [e-mail]
State / Rovince / Fbgion
NC
Country
Us

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:* NCG210384