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HomeMy WebLinkAboutNCG080962_Name-Owner Change Form_2/24/2019Action History (UTC-05:00) Eastern Time (US & Canada) Submit by Anonymous User 2/24/2019 5:29:55 PM (Name Change Submission) Approve by McCoy, Suzanne 4/18/2019 8:48:37 AM (Notification to Admin) • The task was assigned to McCoy, Suzanne 2/24/2019 5:29 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) #: NCG080962 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: Amazon.com.dedc LLC Company farre b. Person legally responsible for permit: First name:* Middle name: Last name:* Kevin Winston Title: Global Environmental Field Leader Permit holder's mailing address:* Phone #:* 925- 577- 5326 c. Facility name:* d. Facility address:* Fax #: Street Address P.O. Box 80842 Address Line 2 ATTN: E. Chapman oty State / Province / Fbgion Seattle Washington Fbstal / Zip Code Country 98108 United States Amazon.com.dedc LLC - CLT2 Street Address 10240 Old Dowd Rd Address Line 2 oty State / Province / Fbgion Charlotte North Carolina Fbstal / Zip Code Country 28214 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: Amazon.com Services, Inc. Conpany Narre c. Person to be legally responsible for permit: First name:* Middle name: Last name:* Kevin Winston Title: Global Environmental Field Leader Permit holder's mailing address:* Street Address P.O. Box 80842 Address Line 2 ATTN: E. Chapman aty Seattle Postal / Zip Code 98108 Phone #:* Email address:* 925- winskevi 577- @amazo 5326 n.com d. Faciltiy name:* Amazon.com Services, Inc. - CLT2 Is the FACILITY contact different than the person legally responsible above?* r Yes f No f. Facility contact person: First name:* Eric Phone #:* Middle name: 206-413-4526 Email address:* echapm@amazon.com Last name:* Chapma n State / Province / Plegion Washington Country United States IV. Permit Contact Information Is the PERMIT contact different than the person legally responsible above? r Yes r No IV. Permit contact information (if different form the person legally responsible for the permt) ............................................................................................................................................................................ First Name:* Middle Last Name:* Eric Name: Chapma n Title: Environmental Program Manager Mailing Address:* Street Address P.O. Box 80842 Address Line 2 ATTN: E. Chapman City Seattle Pbstal / Zip Code 98108 Phone #:* 206-413-4526 Email Address:* echapm@amazon.com State / Province / Fbgion Washington Country United States 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 wl/l 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. NCG080962