NCG020689_Name-Owner Change Form_9/12/2019

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 9/12/2019 2:26:18 PM (Name Change Submission)
Approve by McCoy, Suzanne 9/24/2019 12:31:07 PM (Notification to Admin)
• The task was assigned to McCoy, Suzanne 9/12/2019 2:26 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) #:
NCG020689
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: North American Emerald Mine Inc.
Company �Jarre
b. Person legally responsible for permit:
First name:* Middle name
James
Title:
Permit holder's mailing address:*
Phone #:*
828-
635-
8080
c. Facility name:*
d. Facility address:*
Fax #:
Last name:*
Hill, Jr.
Street Address
531 Duncan Lane
Address Line 2
aty
Hiddenite
Fbstal / Zip Code
28636
State / Rovince / Fbgion
North Carolina
Country
United States
North American Emerald Mines, Inc.
Street Address
531 Duncan Lane
Address Line 2
aty
Hiddenite
Fbstal / Zip Code
28636
e. Facility contact person (prior to change, optional):
First name: Middle name: Last name:
James Hill, Jr
Phone #: [phone]
State / Province / Region
NC
Country
United States

III. Requested Change Information
III. Please provide the following for the requested change (revised permit).
a. Request for changes is a result F Change in ownership of facility
of: * r Name Change of the facility or owner
b. Permit to be issued to:* Martin Marietta Materials, Inc.
Coapany f brre
c. Person to be legally responsible for permit:
First name:* Middle name: Last name:*
Larry Roberts
Title: Mid -Atlantic Division President
Permit holder's mailing address:*
Street Address
413 S. Chimney Rock Road
Address Line 2
City
State / Province / legion
Greensboro
NC
Postal / Zip Code
Country
27409
United States
Phone #:*
Email address:*
336-
larry.rob
389-
erts@ma
6633
rtinmariet
ta.com
d. Faciltiy name:*
Alexander Quarry
e. Facility address:*
Street Address
531 Duncan Lane
Address Line 2
aty
State / Province / legion
Hlddenite
NC
Postal / Zip Code
Country
28636
United States
Is the FACILITY contact different than the person legally responsible
above?*
r Yes
f No
f. Facility contact person:
First name:* Middle name: Last name:*
Jay Nivens
Phone #:* 704-409-1475
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:*
Jay Name: Nivens
Title:
Mailing Address:* Street Address
8701 Red Oak Blvd
Address Line 2
Suite 540
city
Charlotte
Fbstal / Zip Code
28217
Phone #:* 704-409-1475
Email Address:* [e-mail]
State / Rovince / Fbgion
North Carolina
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.
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 docurrentationfor ownership change
Mountain Gems to Martin Marietta REI
Deed Book 601 Page 672 14 Acre Parcel 118.31 KB
8-3-2017. pdf
Sulphur Springs Properties to Martin
Marietta REI Deed Book 619 Page 2042 178.44KB
80 Acre Parcel 8-30-2019.pdf
pdf 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
1 ff11V rG ej1
Fbrrrit-holder prior to the ownership change, or perrrit-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 whom 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.lucaslcDncdenr.gov.

Initial Review
Project ID: * Pleviewer rray revise perrrit number here i incorrect.
NCG020689