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HomeMy WebLinkAboutNCG030227_Name-Owner Change Form_12/06/2018� 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) #: NCG030227 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: Corning Cable Systems LLC Conpany lane b. Person legally responsible for permit: First name:* Middle name: Last name:* Brian Witz Title: Plant Manager Permit holder's mailing address:* Phone #:* 336- 336- 771- 771- 8030 8062 c. Facility name:* d. Facility address:* Fax #: Street Address 3180 Centre Park Boulevard Address Line 2 aty State / Rovince / Fbgion Winston-Salem NC Fbstal / Zip Code Country 27107 us Corning Cable Systems LLC Street Address 3180 Centre Park Boulevard Address Line 2 aty State / Province / Fbgion Winston-Salem NC Fbstal / Zip Code Country 27107 us e. Facility contact person (prior to change, optional): First name: Middle name: Last name: Brian Witz Phone #: 336-771-8030 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: Corning Optical Communications LLC Company Narre c. Person to be legally responsible for permit: First name:* Middle name: Last name:* Brian Witz Title: Plant Manager Permit holder's mailing address:* Street Address 3180 Centre Park Boulevard Address Line 2 aty Winston-Salem Wstal / Zip Code 27107 State / Rovince / Fbgion NC Country us Phone #:* Email address:* 336- Brian.Wit 771- z@Corni 8030 ng.com d. Faciltiy name:* Corning Optical Communications LLC Is the FACILITY contact different than the person legally responsible above?* r Yes r No 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 0�«w W.?Z 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 The Stormwater Program at (919) 707-3639 or e-mail Annette Lucas at annette.lucaslcDncdenr.gov. Initial Review Project ID: * Fbviewer may revise perrrit number here if incorrect. NCG030227