NCG080107_Name-Owner Change Form_11/20/2018

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) #:
NCG080107
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: Con -Way Freight Inc
Conpany farce
b. Person legally responsible for permit:
First name:* Middle name: Last name:*
Jeff Sexten
Title: Manager of Environmental Compliance
Permit holder's mailing address:*
Phone #:*
734-
757-
1657
c. Facility name:*
d. Facility address:*
Fax #:
Street Address
2211 Old Earhart Road
Address Line 2
Suite 100
aty State / Rovince / Fbgion
Ann Arbor MI
Fbstal / Zip Code Country
48105 United States
Con -Way Freight - NIL
Street Address
2704 Horace Watson Road S
Address Line 2
aty State / Rovince / Fbgion
Wilson NC
Fbstal / Zip Code Country
27893 United States
e. Facility contact person (prior to change, optional):
First name:
Phone #:
Middle name: Last name:

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: XPO Logistics Freight, Inc.
Company %rre
c. Person to be legally responsible for permit:
First name:* Middle name: Last name:*
Jeff Sexten
Title: Manager of Environmental Compliance
Permit holder's mailing address:*
Street Address
2211 Old Earhart Road
Address Line 2
Suite 100
City
Ann Arbor
Rxstal / Zip Code
48105
Phone #:* Email address:*
734- Jeff.Sext
757- en@xpo.
1657 com
d. Faciltiy name:* XPO Logisitics Freight, Inc. - NIL
Is the FACILITY contact different than the person legally responsible
above?*
r Yes
r No
State / Rovince / Plegion
MI
Country
United States

IV. Permit Contact Information
Is the PERMIT contact different than the person legally responsible
above?
f Yes
r No

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
FLrrrit-holder prior to the ownership change, or permt-hdder authorizing the narre change
Will another person need to complete or sign this form before it can be submitted? Mo problem! Simply CLICK
the "Save as Draft" button below and send the URL link to the other party to access the form. Questions? Call The
Stormwater Program at [phone] or e-mail Annette Lucas at annette.lucas(a)ncdenr.gov.

Initial Review
Project ID: * Pleviewer rray revise perrrit number here i incorrect.
NCG080107