NCG080063_Owner Affiliation Change_20180911

Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
L Please enter the permit number for which the change is requested.
Coleen H. Sullins, Director
Division of Water Quality
III. Please provide the following for the requested change (revised permit).
a.
NPDES Permit
(or) Certificate of Coverage
N
C', 0 ,0' 1 1 1 1 1 1
1 N G 0 1 8 1 0 0 6 3
II. Permit status nrior to status change.
All employees and management are the City of Charlotte so the City
a.
Permit issued to (company name):
Mecklenburg County Fleet Management Facilty
b.
Person legally responsible for permit:
Vic Reese
Michael Davis, ,
First MI Last
Fiisl+`,; tip, ,., ° `� • ' �Lastr
Division Director
City Engineer
Title
Title
900 West 12th Street
City of Charlotte Engineering and Property
Permit Holder Mailing Address
Management 14th Floor, 600 East 4th Street
Charlotte NC 28206
Permit Holder Mailing Address
City State Zip
Charlotte NC 28202
[phone] ( )
City State Zip
Phone Fax
c.
Facility name (discharge):
Mecklenburg County Fleet Maintenance
d.
Facility address:
900 West 12th Street
Mecklenburg County Fleet Maintenance
e.
Address
900 West 12th Street
Charlotte NC 28206
Address
City State Zip
e.
Facility contact person:
Wayne Keith [phone]
City State Zip
f.
First / MI /Last Phone
III. Please provide the following for the requested change (revised permit).
a.
Request for change is a result of.
❑ Change in ownership of the facility
® Name change of the facility or owner
All employees and management are the City of Charlotte so the City
If other please explain:
would like to take ownership of the permit
b.
Permit issued to (company name):
City of Charlotte
c.
Person legally responsible for permit:
Michael Davis, ,
Fiisl+`,; tip, ,., ° `� • ' �Lastr
City Engineer
Title
City of Charlotte Engineering and Property
Management 14th Floor, 600 East 4th Street
Permit Holder Mailing Address
Charlotte NC 28202
City State Zip
[phone] madavis [e-mail] ,
Phone E-mail Address
d.
Facility name (discharge):
Mecklenburg County Fleet Maintenance
e.
Facility address:
900 West 12th Street
Address
Charlotte NC 28206
City State Zip
f.
Facility contact person:
Marcus McAdoo
First MI Last
Revised 812008

PERMIT NAME/OWNERSHIP CHANGE FORM
Page 2 of 2
[phone] mmcadoo aci.charlotte.nc.us
Phone E-mail Address
IV. Permit contact information (if different from the person legally responsible for the permit)
Permit contact: Kristen A O'reilly
First MI Last
Water Quality Program Specialist
Title
Charlotte Storm Water Services, 600 E. 4t" St, 14t"
Floor
Mailing Address
Charlotte NC 28202
City State Zip
[phone] koreilly(aci.charlotte.nc.us
Phone E-mail Address
V Will the permitted facility continue to conduct the same industrial activities conducted prior
to this ownership or name change?
® Yes
❑ No (please explain)
VI. Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS
ARE INCOMPLETE OR MISSING:
❑ This completed application is required for both name change and/or ownership change
requests.
❑ Legal documentation of the 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.
The certifications below must be completed and signed by both the permit holder prior to the change, and
the new applicant in the case of an ownership change request. For a name change request, the signed
Applicant's Certification is sufficient.
PERMITTEE CERTIFICATION (Permit holder prior to ownership change):
I, , attest that this application for a name/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 and that if all required supporting information is not included, this application package will be
returned as incomplete.
YI`G RSCSc /f no /VWcr H/;"" _01t"4
Signature, Signature
APPLICANT CERTIFICATION
Date
I, Kristen O'Reilly, attest that this application for a name/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 and that if all required supporting information is not included, this application
package will be returned as incomplete.
a06(,4_ 0�� C K boh
Signature6 Date
PLEASE SEND THE COMPLETE APPLICATION PACKAGE TO:
Division of Water Quality
Surface Water Protection Section
1617 Mail Service Center
Revised 712008