NCG170242_Name-Owner Change Form_8/28/2018

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) #:
NCG170242
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: Glen Raven Inc.
Companylarre
b. Person legally responsible for permit:
First name:* Middle name: Last name:*
Edmund Gant, Jr.
Title:
Permit holder's mailing address:*
Phone #:*
336-
221-
2104
c. Facility name:*
d. Facility address:*
Fax #:
Street Address
1821 North Park Avenue
Address Line 2
City
State / Rovince / Fbgion
Burlington
NC
Fbstal / Zip Code
Country
27217
us
Glen Raven Inc
Street Address
1821 North Park Avenue
Address Line 2
City
State / Rovince / Fbgion
Burlington
NC
Fbstal / Zip Code
Country
27217
us
e. Facility contact person (prior to change, optional):
First name: Middle name: Last name:
Andrea Saurage
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: Shawmut Park Avenue, LLC
Conpany Nacre
c. Person to be legally responsible for permit:
First name:* Middle name: Last name:*
Edmund Gant, Jr.
Title:
Permit holder's mailing address:*
Street Address
Andrea
Saurage
Phone #:*
1821 North Park Avenue
Email address:*
[e-mail]
Address Line 2
aty
State / Province / Pegion
Burlington
NC
Wstal / Zip Code
Country
27217
us
Phone #:*
Email address:*
336-
egantjr@
221-
shawmut
2104
corporati
on.com
d. Faciltiy name:*
Shawmut Park Avenue, LLC
e. Facility address:*
Street Address
1821 North Park Avenue
Address Line 2
Oty
State / Province / Fbgion
Burlington
NC
Wstal / Zip Code
Country
27217
us
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:*
Andrea
Saurage
Phone #:*
336-221-2253
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:*
Jordan Name: McDevitt
Title:
Mailing Address:* Street Address
1821 North Park Avenue
Address Line 2
aty
Burlington
F bstal / Zip Code
27217
Phone #:* 336-221-2124
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.
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
Active_105423789_1_Project Roadway -
GRTF Bill of Sale (executed)- for Name 265.01 KB
Change.pdf
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
FLrrrit-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 rr��
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:* NCG170242