NCG110043_Name-Owner Change Form_20180820

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) #:
NCG110043
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: City of Kinston
Corrpany f brre
b. Person legally responsible for permit:
First name:* Middle name: Last name:*
Tony Sears
Title: City Manager
Permit holder's mailing address:*
Phone #:*
25293
93375
c. Facility name:*
d. Facility address:*
Fax #:
25293
93741
Street Address
2101 Becton Farm Road
Address Line 2
oty
Kinston
Fbstal / Zip Code
28501
State / Province / Fbgion
NC
Country
us
Kinston Regional Water Reclamation Facility
Street Address
2101 Becton Farm Road
Address Line 2
oty
Kinston
Fbstal / Zip Code
28501
e. Facility contact person (prior to change, optional):
First name
Phone #:
Middle name: Last name:
State / Province / Pegion
NC
Country
us

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: Johnnie Mosley Regional Water Reclamation Facility
Corrpany Nacre
c. Person to be legally responsible for permit:
First name:* Middle name
Tony R
Title:
Permit holder's mailing address:*
Last name:*
Sears
Street Address
2101 Becton Farm Road
Address Line 2
aty
Kinston
Rxstal / Zip Code
28501
Phone #:* Email address:*
25293 kenneth.
93375 stevens
@ci. kinst
on.nc.us
State / Province / Fbgion
NC
Country
us
d. Faciltiy name:* Johnnie Mosley Regional Water Reclamation Facility
Is the FACILITY contact different than the person legally responsible
above?*
r Yes
f No
f. Facility contact person:
First name:*
Kenneth
Phone #:*
Middle name:
R
2529393375
Last name:*
Stevens,
Jr.
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 perrrit)
...................................................................................................................................................................................................................
First Name:* Middle Last Name:*
Kenneth Name: Stevens,
R Jr.
Title: Reclamation Superintendent
Mailing Address:* Street Address
2101 Becton Farm Road
Address Line 2
aty
Kinston
F bstal / Zip Code
28501
Phone #:* 2529393375
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
194w4wa; 07�.
FL-rrrit-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:* NCG110043