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HomeMy WebLinkAboutNCGNE0018_Name-Owner Change Form_11/26/2018� ST1V{ NORTH C:Ft iO�INA ErtYfranminlQf QYQiff}� 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) #: NCG NE0018 NC GX XX XX X 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 Southern Express Corrpany f hrre 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 Michigan Fbstal / Zip Code Country 48105 Unites States Con -Way Southern Express - NCH Street Address 6701 Old Statesville Road Address Line 2 aty State / Rovince / Fbgion Charlotte North Carolina Fbstal / Zip Code Country 28269 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. - NCH Is the FACILITY contact different than the person legally responsible above?* r Yes r No State / Frovince / Plegion Michigan 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 (919) 707-3639 or e-mail Annette Lucas at annette.lucas(a)ncdenr.gov. Initial Review Project ID: * Fbviewer may revise perrrit number here if incorrect. NCGNE0018