NCG240004_Name-Owner Change Form_20190822

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 8/22/2019 9:32:33 AM (Name Change Submission)
Approve by McCoy, Suzanne 8/28/2019 11:59:21 AM (Notification to Admin)
• The task was assigned to McCoy, Suzanne 8/22/2019 9:32 AM

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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) #:
NCG240004
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: McGill Environmental Systems of NC, Inc.
Conpanytarre
b. Person legally responsible for permit:
First name:* Middle name:
Last name:*
Michael Noel
Lyons
Title:
President
Permit holder's mailing address:*
Street Address
P.O. Box 61
Address Line 2
aty
State / Rovince / Fbgion
Harrells
NC
Fbstal / Zip Code
Country
28444
USA
Phone #:*
919-
532-
2539
c. Facility name:*
d. Facility address:*
Fax #:
Delway Facility
Street Address
1100 Herring Road
Address Line 2
aty
State / Province / Fbgion
Rose Hill
NC
Fbstal / Zip Code
Country
28458-7618
US
e. Facility contact person (prior to change, optional):
First name: Middle name: Last name:
Steve Cockman
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: McGill Environmental Systems of NC, Inc
Corrpany Nacre
c. Person to be legally responsible for permit:
First name:* Middle name:
Last name:*
Michael Noel
Lyons
Title:
President
Permit holder's mailing address:*
Street Address
P. O. Box 61
Address Line 2
Oty
State / Rovince / Fbgion
Harrells
NC
F bstal / Zip Code
Country
28444
USA
Phone #:* Email address:*
919- nlyons@
532- mcgillco
2539 mpost.co
m
d. Faciltiy name:* Delway Facility
Is the FACILITY contact different than the person legally responsible
above?*
r Yes
f No
f. Facility contact person:
First name:*
Misti
Phone #:*
Middle name:
919-770-4416
Last name:*
Benchab
bat
Email address:* [e-mail]

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:*
Misti Name: Benchab
bat
Title: Compliance Manager
Mailing Address:* Street Address
634 Christian Chapel Church Road
Address Line 2
aty State / Rovince / Fbgion
New Hill North Carolina
Fbstal / Zip Code Country
27562 United States
Phone #:* 9197704416
Email Address:* [e-mail]

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
N6 PwA46t
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 [phone] or e-mail Annette Lucas at annette.lucaslcDncdenr.gov.

Initial Review
Project ID: * Fbviewer may revise perrrit number here if incorrect.
NCG240004