NCS000292_Name-Owner Change Form_20180809

Environmental
Quakry
I. Permit Information
I. Please enter the permit number for which the change is requested.
NPDES Stormwater Individual Permit #:
NCS000292
NC
sx
xx
xx
x
-OR-
General Permit Certificate of Coverage (COC) #:
NC
CDC
xx
xx
x
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: Resinall Corporation
Conpany Nlarre
b. Person legally responsible for permit:
First name:* Middle name: Last name:*
Lee Godina
Title:
Permit holder's mailing address:*
Phone #:*
25258
51445
c. Facility name:*
d. Facility address:*
Fax #:
Street Address
302 N. Water Street
Address Line 2
P.O. Box 195
aty State / Rovince / Fbgion
Severn NC
Fbstal / Zip Code Country
27877 United States
Resinall Corporation
Street Address
302 N. Water Street
Address Line 2
P.O. Box 195
aty State / Rovince / Fbgion
Severn NC
Fbstal / Zip Code Country
27877 United States
e. Facility contact person (prior to change, optional):
First name: Middle name: Last name:
Paul Pearce
Phone #: [phone]

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:* Ergon Chemicals, LLC
Conpany Farre
c. Person to be legally responsible for permit:
First name:*
Middle name:
Last name:*
Kris
Patrick
Title:
Chief Operating Officer
Permit holder's mailing address:*
Street Address
P.O. Box 1639
Address Line 2
City
State / Province / legion
Jackson
MS
Fbstal / Zip Code
Country
39215
United States
Phone #:*
Email address:*
60193
kris.patri
33000
ck@ergo
n.com
d. Faciltiyname:*
Resinall Corporation
e. FaciIityadd ress: *
Street Address
302 N. Water Street
Address Line 2
City
State / Province / legion
Severn
NC
Fbstal / Zip Code
Country
27877
United States
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:*
Paul Pearce
Phone #:* 2525851445
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:*
Austin
W
Title:
Mailing Address:*
Middle Last Name:*
Name: Moody
Phone #:* 6019333521
Environmental Engineer
Street Address
P.O. Box 1639
Address Line 2
City
Jackson
Fbstal / Zip Code
39215
Email Address:* [e-mail]
State / Rovince / Fbgion
ms
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 docurrentation for ownership change
2018 Severn Water Permit Transfer
949.52KB
Upload.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
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
C)&Z c 6
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:* NCS000292