NCG210368_Name-Owner Change Form_9/4/2018

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) #:
NCG210368
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: ITL Corporation(Industrial Timber&Lumber)
Conpany Wfe
b. Person legally responsible for permit:
First name:* Middle name: Last name:*
Larry C Hensley
Title: Safety Director Manager
Permit holder's mailing address:*
Phone #:*
216-
258-
c. Facility name:*
d. Facility address:*
Fax #:
Street Address
35748 State Highway 93
Address Line 2
aty
Hamden
Fbstal / Zip Code
45634-8872
State / Province / Pegion
OH
Country
us
ITL Corp. Industrial Timber &Lumber
Street Address
203 College Drive
Address Line 2
aty
Marion
R stal / Zip Code
28752
e. Facility contact person (prior to change, optional):
First name: Middle name: Last name:
James Shill
Phone #: [phone]
State / Province / Fbegion
North Carolina
Country
McDowell

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: Northwest Hardwoods Inc.
Corrpany f brre
c. Person to be legally responsible for permit:
First name:* Middle name: Last name:*
Rick Motter
Title: Health & Safety Manager
Permit holder's mailing address:*
Street Address
10589 Campbell Road
Address Line 2
aty
Titusville
Fbstal / Zip Code
16354
Phone #:* Email address:*
814- rick. mott
874 er@mort
hwesthar
dwoods.c
om
d. Faciltiy name:* Northwest Hardwoods
Is the FACILITY contact different than the person legally responsible
above?*
r Yes
f No
f. Facility contact person:
First name:*
Larry
Phone #:*
Middle name
216-258-4580
Last name:*
Hensley
Email address:* [e-mail]
State / Province / Flegion
PA
Country
us

IV. Permit Contact Information
Is the PERMIT contact different than the person legally responsible
above?*
f• Yes
r No
IV. Permit contact information
(if different form the person legally responsible for the permt)
....................................................................................................................................................................................................
First Name:*
Middle Last Name:*
Larry
Name: Hensley
Title:
Safety Manager
Mailing Address:*
Street Address
35748 State Route 93
Address Line 2
City
Hamden
Postal / Zip Code
45634-8872
Phone #:* 216-258-4480
Email Address:* [e-mail]
State / Province / Fbgion
OH
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
Fbrrrit-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:* NCG210000