NCG020504_Name-Owner Change Request_20180711

State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
STATE STORMWATER PERMIT NAME/OWNERSHIP CHANGE FARM
I. CURRENT PERMIT INFORMATION �Cc/
NCG020504 *4i �
1. Stormwatgr Management Permit Number: _ _ _ nom.. � 1?
CR��
2. Project Name: Forterra Brick - Gulf Mine 3 _ � q� D, '
3. Current Permit Holder's Company Name/Organization: —Forterra Brick LLC
4 -Signing Official's Name' J_David McKiovwn– Title: Regional Environmental Manac)'er
15. Flailing Address: 5100 Brickyard Road
City: Columbia --- --- State: SC — Zip: 29203
6. Phone:( 03 ) 691-3121 Fax: ! l03 ) 786-9703 -- --
!E. PROPOSED PERMITTEE! OWNER /PROJECT/ A(DDRESS INFORMATION
This request is tor: (please check all that apply)
[] Name change of the owner (Please complete Iters 1, 2 and 3 below)
❑ Name change of project (Please complete Item 5 below)
J Change in ownership of the property/company'Please complete Items 1, 2, 3, and 4 below)
❑ Mailing address / phone number change. (Please complete Item 4 below)
E] Other (please explain):_ -
1. Proposed permittee's company name/organization: Meridian Brick LLC
2. Proposed r ermittee's signing official's name. J. David McKeown
:1.'Proposed permittee's.title: �Corpor.aie Envccnmcntal Manager.
4. Mailing Address: 5100 Brickyard Road _—
City: _ Columbia
Phone: (_803 ) 691-3121
5. New Project Name to be placed on permit:
State: _SC Zip: 29203
Fax. ( 803 ) 786-9703 ---
Meriaian Brick LLC - Gulf Mine 3
Please check the appropriate box. The proposed permittee listed above is:
HOA or ROA (Attach documentation showing that the HOA or POA owns, controls, or has a
recorded easement for ail areas that contain stormwater system features. Print name of HOA or
POA in #1' above and provide name of HOA/POA's authorized representative in #2 above)
The property owner
❑ Lessee (Attach a copy of the lease agreement and complete Property Owner Information on
page 4)
El Purchaser (Attach a copy of the pandirg sales agreement. Final approval of this transfer will be
granted upon receipt of a copy of the recorded deed)
❑ Developer (Complete Property Owner Information on page 4)
SSW N/0 Change Rev24Sept2012 Page 1 of 4

J

III. REQUIRED ITEMS
A request to transfer a permit will not be approved by the Division of Water Quality (DWQ) unless all
of the applicable required items listed below are included with the submittal. Failure to provide the
listed items may result in processing delays or denial of the transfer. ,
1. This completed and signed form. This certification must be completed and,signed by both the
current permitholder and the new applicant if this is a change of ownership.
2. Legal documentation of the property transfer to a new owner.
3. A copy of any recorded deed restrictions, covenants, or easements, if required by the permit.
4. The designer's certification (DWQ Engineer and Designer Certification Forms are available from
each DWQ Regional office), if required by the permit and if not already submitted to DWQ.
5. If the proposed permittee is a firm, partnership, association, institution, corporation, limited liability
company, or other corporate entity, provide documentation showing the authority of the named
representative to act on behalf of the proposed permittee.
6. The $40.00 processing fee. If this is an initial transfer from the original permittee the processing
fee is not required. Subsequent ownership transfers will require the $40.00 processing fee.
.IV. CURRENT PERMITTEE'S CERTIFICATION
Please check one of the following statements and fill out the certification below that statement..
® Check here. if the current permittee isply changing his/herfits name, the project name, or mailing
address, but will retain the permit. I, •� >_ Yj,Y , the current .
permittee, hereby notify the DWQ that I 4fn changing my name and/or I am changing my mailing
address and/or I am changing the name of the permitted project. I further attest that this application
for a name/ownership change 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
and attachments -listed above are not included, this application package will be returned as
incomplete.
Check here if current permittee is transferring the property to a new owner and will not retain .
ownership of the permit.
I, , the current permittee, am submitting this application
for a transfer of ownership for permit # . I hereby notify DWQ of the sale or
other legal transfer of the stormwater system associated with this permit. I have provided a copy of
the. most recent permit, the designer's certification for each BMP, any recorded deed restrictions,
covenants, or easements, the DWQ approved plans and/or approved as -built plans, the approved
operation and maintenance agreement, past maintenance records, and the most recent DWQ
stormwater inspection report to the proposed permittee named in Sections II and V of this form. I
further attest -that this application for a name/ownership change 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 and attachments listed above are not included, this application
package will be returned as incomplete. I assign all rights and obligations as permittee to the
proposed permittee named in Sections 11 and V of this form. I understand that this transfer of
ownership cannot be approved by the DWQ unless and until the facility is in compliance with the
permit.
Signature:
County of
Date:
a Notary Public for the State of
do hereby certify that .
personally appeared before me this the
day of , 20 , and acknowledge the due execution of the
forgoing instrument. Witness my hand and official seal,
Notary Signature
SSW N/O Change Rev24Sept2012 Page 2 of 4
(Notary Seal)

V. PROPOSED PERMITTEE CERTIFICATION: (This section must be completed by the
Proposed Permittee for all transfers of ownership)
hereby notify the DWQ that I have acquired
through sale, lease or legal transfer, the responsibility for operating and maintaining the permitted
stormwater management system, and, if applicable, constructing the permitted system. I
acknowledge and attest that I have received a copy of: (check all that apply to this permit)
®the most recent permit
the designer's certification for each BMP
❑ any recorded deed restrictions, covenants, or easements
❑ the DWQ approved plans and/or approved as -built plans
❑ the approved operation and maintenance agreement
®past maintenance records from the previous permittee (where required)
DWQ stormwater inspection report showing compliance within 90 days prior to this transfer
I have reviewed the permit, approved plans and other documents listed above, and I will comply with
the terms and conditions of the permit and approved plans. I acknowledge and agree that I will
operate and maintain the system pursuant to the requirements listed in the permit and in the
operation and maintenance agreement. I further attest that this application for a name/ownership,-
change 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 and attachments listed
above are not included, this application package will be returned as incomplete.
Signature:
Date:
a Notary Public for the State of
County of , do hereby certify that
personally appeared before me this the
day of , 20 , and acknowledge the due execution of the
forgoing instrument. Witness my hand and official seal,
(NotarySeal)
Notary Signature
Additionalcopies of the original permit and the approved Operation and Maintenance agreement can
be obtained from the appropriate Regional Office of the Division of Water Quality.
This completed form, including all supporting documents and processing fee (if required), should be
sent to the apppropriate Regional Office of the North Carolina Department of Environment and Natural
Resources, Division of Water Quality, as shown on the attached map.
Please note that if the Proposed Permittee listed above is not the property owner, the property owner
must complete and sign page 4 of this document. Both the lessee /developer and the property
owner will appear on the permit as permittees.
SSW N/O Change Rev24Sept2012 Page 3 of 4

VI. PROPERTY OWNER CONTACT INFORMATION AND CERTIFICATION
If the Proposed Permittee listed in Sections 11 and V of this form is not the Property Owner, the
Property Owner frust provide his/her Contact Information below and sign this form:
Printed Name:
Organization:
Title within the Organization:
Street Address:
City:
Mailing Address:
City:
Phone:
State:
(if different from street address)
State:
Fax:
Zip:
Zip:
Email:
I certify that I own the property identified in this permit transfer document and have given permission
to the Proposed Permittee listed in Sections II and V to develop and/or, lease the property. A copy
of the lease agreement or other contract, which indicates the party responsible for the construction
and/or operation and maintenance of the stormwater system, has been provided with the submittal.
As the legal property owner I acknowledge, understand, and agree by my signature below, that I will
appear as a permittee along with the lessee/developer and I will therefore share responsibility for
compliance with the DWQ Stormwater permit. As the property owner, it is my responsibility to notify
DWQ by submitting a completed Name/Ownership Change Form within 30 days of procuring -a
developer; lessee or purchaser for the property. I understand that failure to operate and maintain the
stormwater treatment facility in accordance with the permit is a violation of NC General Statute
(NCGS) 143-215.1, and may result in appropriate enforcement action including the assessment of
civil penalties of up to $25,000 per day, pursuant to NCGS 143-215.6.
Signature of the property owner
Date:
a Notary Public for the State of
County of ; do hereby certify that
personally appeared before me this the
day of , 20 , and acknowledge the due execution of the
forgoing 'instrument. Witness my hand and official seal,
(Notary Seal)
Notary Signature
SSW N/O Change Rev24Sept2012 Page 4 of 4