NCGNE1281_Affiliation Changes_20181130

A7411; Division of Energy, Mineral & Land Resources
— �Land uali Section/Stormwater Permittin��- Q g
NCDENR National Pollutant Discharge Elimination System
NORTH CAROUNA DEPARTMENT OF
ENVIRONMENT AND NAUR-RESOURCES PERMIT NAME/OWNERSHIP CHANGE FORM
FOR AGENCY USE ONLY
Date Received
Year
Month
Day
I. Please enter the permit number for which the change is requested.
NPDES Permit
(or) Certificate of Coverage
N C S
N E 1 2 M81
II. Permit status pLi2r to requested change.
a. Permit issued to (company name):
Old Dominion Freight Line, Inc.
b. Person legally responsible for permit:
Sam Faucette
First MI Last
Title
500 Old Dominion Way
Permit Holder Mailing Address
Thomasville NC 27360
City State Zip
[phone] ( )
Phone Fax
c. Facility name (discharge):
Old Dominion Freight Line Kings Mountain
d. Facility address:
604 Innovation Drive
Address
Kings Mountain NC 28086
City State Zip
e. Facility contact person:
( )
First / MI / Last Phone
III. Please provide the following for the requested change (revised permit).
a. Request for change is a result of:
❑ Change in ownership of the facility
® Name change of the facility or owner
If other please explain: This is only to update the LRP and facility contact person
b. Permit issued to (company name):
Old Dominion Freight Line, Inc.
c. Person legally responsible for permit:
Terry Hutchins
First MI Last
Vp - Real Estate
Title
500 Old Dominion Way
Permit Holder Mailing Address
Thomasville NC 27360
City State Zip
[phone] [e-mail]
Phone E-mail Address
d. Facility name (discharge):
Old Dominion Freight Line Kings Mountain
e. Facility address:
604 Innovation Drive
Address
Kings Mountain NC 28086
City State Zip
f. Facility contact person:
Joseph Fuhr
First MI Last
[phone] joseph.fuhr podfl.com
Phone E-mail Address
Revised Jan. 27, 2014

NPDES PERMIT NAME/OWNERSHIP CHANGE FORM
Page 2 of 2
IV. Permit contact information (if different from the person legally responsible for the permit)
Permit contact: Joseph Fuhr
First MI Last
Manager - Real Estate Environmental Services
Title
500 Old Dominion Way
Mailing Address
Thomasville NC 27360
City State Zip
[phone] [e-mail]
Phone E-mail Address
V. Will the permitted facility continue to conduct the same industrial activities conducted prior
to this ownership or name change?
® Yes
❑ No (please explain)
VI. Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS
ARE INCOMPLETE OR MISSING:
❑ This completed application is required for both name change and/or ownership change
requests.
❑ Legal documentation of the 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.
The certifications below must be completed and signed by both the permit holder prior to the change, and
the new applicant in the case of an ownership change request. For a name change request, the signed
Applicant's Certification is sufficient.
PERMITTEE CERTIFICATION (Permit holder prior to ownership change):
I, Joseph Fuhr, attest that this application for a name/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 and that if all required supporting information is not included, this application package will be
returned as incomplete.
)v,,, --Vv� &t-� - 1� 1-2,-7 � I (�
Signature Date
A ICANT CERTIFICATION
I, , attest that this application for a name/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 and that if all required supporting information is not included, this application package will be
returned as incomplete.
Signature
Date
PLEASE SEND THE COMPLETE APPLICATION PACKAGE TO:
Division of Energy, Mineral and Land Resources
Stormwater Permitting Program
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
Revised Jan. 27, 2014