NCG080927_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) #:
NCG080927
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
Conpany f hre
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 - NLB
Street Address
4715 W 5th Street
Address Line 2
aty State / Rovince / Pegion
Lumberton NC
Fbstal / Zip Code Country
28358 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 Logistics Freight, Inc. - NLB
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 (1) 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? 11/o 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.
NCG080927