NCG050318_Name-Owner Change Form_7/25/2018

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) #:
NCG050318
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:*
Parker Hannifin Corporation -Tech Seal Div
Company Barre
b. Person legally responsible for permit:
First name:* Middle name
Steven
Title:
Permit holder's mailing address:*
Phone #:*
25223
71738
c. Facility name:*
d. Facility address:*
Fax #:
Last name:*
Minnich
Street Address
2600 Wilco Blvd S
Address Line 2
aty
State / Province / Fbgion
Wilson
NC
Fbstal / Zip Code
Country
27893
Wilson
Parker Techseal
Street Address
2600 Wilco Blvd S
Address Line 2
aty
State / Province / Fbgion
Wilson
NC
Fbstal / Zip Code
Country
27893
Wilson
e. Facility contact person (prior to change, optional):
First name:
Phone #:
Middle name: Last name:

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: Wilco Blvd, LLC
Corrpany fibre
c. Person to be legally responsible for permit:
First name:* Middle name: Last name:*
Justin Mallon
Title:
Permit holder's mailing address:*
Street Address
813 Graham St
Address Line 2
Oty
Emporia
Rxstal / Zip Code
66801
Phone #:*
Email address:*
620-
justinmall
342-
on@ever
6622
greendes
ign-
build.com
d. Faciltiy name:*
Wilco Blvd
e. Facility address:*
Street Address
2600 Wilco Blvd S
Address Line 2
Oty
Wilson
Wstal / Zip Code
27893
Is the FACILITY contact different than the person legally responsible
above?*
r Yes
f• No
State / Rovince / Plegion
Ks
Country
Lyon
State / Rovince / Region
NC
Country
Wilson

IV. Permit Contact Information
Is the PERMIT contact different than the person legally responsible
above?
f Yes
r No

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
If no, please explain:* The property does not have a current tenant and don't believe it
has been operating for several months.

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
Wilco Blvd - NC Division of Energy.pdf 12.53KB
pdr 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
� 6WnK0,
F2rrrit-holder prior to the ownership change, or permit -holder authorizing the narre 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
ted 6wa&w
To w horn the permit 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:* NCG050318