NCG180169_Name-Owner Change Form_7/23/2019

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 7/23/2019 2:49:12 PM (Name Change Submission)
Approve by McCoy, Suzanne 7/23/2019 2:57:13 PM (Notification to Admin)
• The task was assigned to McCoy, Suzanne 7/23/2019 2:49 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) #:
NCG180169
NC
GC
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: Heritage Home Group
Conpany Wfe
b. Person legally responsible for permit:
First name:* Middle name: Last name:*
David Stout
Title: Director of Environmental Compliance
Permit holder's mailing address:*
Phone #:*
(828)
406-
6079
c. Facility name:*
d. Facility address:*
Fax #:
Street Address
PO Box 759
Address Line 2
aty
State / Rovince / Fbgion
Taylorsville
NC
Fbstal / Zip Code
Country
28681
U.S.A.
Heritage Home Group Lenoir Wood Plant
Street Address
315 Elizabeth Street
Address Line 2
aty
Lenoir
Fbstal / Zip Code
28645
e. Facility contact person (prior to change, optional):
First name: Middle name: Last name:
David Stout
Phone #: [phone]
State / Rovince / Region
NC
Country
U.S.A.

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: Craftmaster Furniture
Corrpany Nacre
c. Person to be legally responsible for permit:
First name:* Middle name: Last name:*
Kevin Mann
Title: Senior VP of Operations
Permit holder's mailing address:* Street Address
Phone #:*
(828)
632-
9786
d. Faciltiy name: *
e. Facility address:*
PO Box 759
Address Line 2
aty
Taylorsville
Postal / Zip Code
28681
Email address:*
KevinMa
nn@cmfu
rniture.co
m
State / Province / Plegion
NC
Country
U.S.A.
Hamilton Square Lenoir Casegoods Plant
Street Address
315 Elizabeth Street
Address Line 2
aty
Lenoir
Postal / Zip Code
28681
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:*
David Stout
Phone #:* [phone]
Email address:* [e-mail]
State / Province / Fbgion
NC
Country
U.S.A.

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:*
David
Name: Stout
Title:
Environmental Manager
Mailing Address:*
Street Address
PO Box 759
Address Line 2
City
Taylorsville
Fbstal / Zip Code
28681
Phone #:* [phone]
Email Address:* [e-mail]
State / Rovince / Region
NC
Country
U.S.A.

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 docurrentation for ownership change
HHG -
Lenoir Case Real Estate Purchase ... 229.62KB
EXECUTED.pdf
pdr only
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
Permit -holder prior to the ownership change, or permit -holder authorizing the narre 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 permit 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.lucasCa)ncdenr.gov.

Initial Review
Project ID: * Pleviewer rray revise perrrit number here i incorrect.
NCG180169