NCG140002_Name-Owner Change Form_8/1/2019

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 8/1/2019 2:43:41 PM (Name Change Submission)
Approve by McCoy, Suzanne 8/16/2019 1:29:36 PM (Notification to Admin)
• The task was assigned to McCoy, Suzanne 8/1/2019 2:43 PM

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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) #:
NCG140002
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: Greenville Ready Mixed Concrete/ DPD Team
Concrete
Conpany Wfe
b. Person legally responsible for permit:
First name:* Middle name
David
Title:
Permit holder's mailing address:*
Phone #:*
252-
756-
5886
c. Facility name:*
d. Facility address:*
Fax #:
Last name:*
Hardee
Street Address
PO Box 1639
Address Line 2
aty
Winterville
Fbstal / Zip Code
28590
State / Province / Fbgion
NC
Country
us
DPD Team Concrete - Rocky Mount Facility
Street Address
2375 North Wesleyan Boulevard
Address Line 2
aty State / Province / Fbgion
Wilmington North Carolina
Fbstal / Zip Code Country
28403 us
e. Facility contact person (prior to change, optional):
First name: Middle name: Last name:
Aztec Masonry
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: Crete Solutions, LLC
Corrpany l\brre
c. Person to be legally responsible for permit:
First name:* Middle name: Last name:*
John Allen
Title: Partner
Permit holder's mailing address:* Street Address
2005 Eastwood Rd. Suite 200
Address Line 2
aty State / Province / Fbgion
Wilmington NC
Fostal / Zip Code Country
28403 United States
Phone #:* Email address:*
910- jda@cret
726- ellc.com
1693
d. Faciltiy name:* Crete Solutions, LLC
e. Facility address:* Street Address
2375 North Wesleyan Boulevard
Address Line 2
Oty State / Province / Plegion
Rocky Mount NC
Postal / Zip Code Country
27804 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:*
Tyler Dickson
Phone #:* 252-442-6181
Email address:* [e-mail]

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.
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
DPD Bill of Sale.pdf 35.58KB
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
R"400146
F2rrrit-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.lucasancdenr.gov.

Initial Review
Project ID: * Fbviewer may revise perrrit number here if incorrect.
NCG140002