NCG140340_Name-Owner Change Form_1/9/2019

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 1/9/2019 4:17:22 PM (Name Change Submission)
Approve by McCoy, Suzanne 4/17/2019 10:51:22 AM (Notification to Admin)
* Only sold Shelby facility. created new owner.
• Georgoulias, Bethany reassigned the task to McCoy, Suzanne 1/11/2019 12:12 PM
• The task was assigned to Georgoulias, Bethany 1/9/2019 4:17 PM

� 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) #:
NCG140340
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: Wellington Hamrick, Inc.
Corrpany Narre
b. Person legally responsible for permit:
First name:* Middle name
Katherin Hamrick
e
Title:
Permit holder's mailing address:*
Phone #:*
70443
46551
c. Facility name:*
d. Facility address:*
Fax #:
70443
42803
Last name:*
Hoyle
President
Street Address
P. O. Box 755
Address Line 2
City
State / Province / Fbgion
Boiling Springs
North Carolina'
Fbstal / Zip Code
Country
28017
USA
Wellington Hamrick, Inc. - Shelby
Street Address
1111 Airport Road
Address Line 2
City
State / Province / Fbgion
Shelby
NC
Pbstal / Zip Code
Country
28150-3640
US
e. Facility contact person (prior to change, optional):
First name: Middle name: Last name:
Jason M Hamrick
Phone #: [phone]

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: BlueDot Readi Mix
Conpany Nacre
c. Person to be legally responsible for permit:
First name:* Middle name: Last name:*
Paul Cochran
e
Title: President
Permit holder's mailing address:*
Street Address
11330 Bain School Road
Address Line 2
Oty
State / Province / Pegion
Mint Hill
NC
Postal / Zip Code
Country
28227-7550
us
Phone #:*
Email address:*
704-
pcochran
971-
e@blued
7676
otreadimi
x.com
d. Faciltiy name:*
BlueDot Shelby
e. Facility address:* Street Address
1100 Airport Rd
Address Line 2
Oty
State / Province / Fbgion
Shelby
NC
Postal / Zip Code
Country
28150-3639
us
Is the FACILITY contact different than the person legally responsible
above?*
r Yes
r No
f. Facility contact person:
First name:* Middle name: Last name:*
Jason Hamrick
Phone #:* 7044722670
Email address:* [e-mail]

IV. Permit Contact Information
Is the PERMIT contact different than the person legally responsible
above?*
f• Yes
r No
IV. Permit contact information
(if different form the person legally responsible for the permt)
....................................................................................................................................................................................................
First Name:*
Middle Last Name:*
Trey
Name: Lowder
Title:
Assitant Operation Manager
Mailing Address:*
Street Address
11330 Bain School Road
Address Line 2
City
Mint Hill
F bstal / Zip Code
28227-7550
Phone #:* 704-301-5600
Email Address:* [e-mail]
State / Rovince / Fbgion
NC
Country
us

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.
Legal documentation of 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.
File Upload:* Upload supporting docurrentationfor ownership change
NC Warranty Deed[5968].pdf 202.5KB
Resolutions approving Sale[5969].pdf 631.52KB
pdr only
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
FL-rnit-holder prior to the ow nership change, or perrrit-holder authorizing the nave change
Applicant 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.
Applicant Signature
To w horn the pernit is to be transferred
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 [phone] or e-mail Annette Lucas at annette.lucas(a)ncdenr.gov.

Initial Review
Project ID: * Pleviewer may revise perrrit number here i incorrect.
NCG140340