NCG170242_Name-Owner Change Form_9/16/2019

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 9/16/2019 1:24:01 PM (Name Change Submission)
Approve by McCoy, Suzanne 9/24/2019 12:57:23 PM (Notification to Admin)
• The task was assigned to McCoy, Suzanne 9/16/2019 1:24 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) #:
NCG170242
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: Shawmut Park Avenue LLC
Company �Jarre
b. Person legally responsible for permit:
First name:* Middle name
Edmund
Title:
Permit holder's mailing address:*
Phone #:*
336-
221-
2104
c. Facility name:*
d. Facility address:*
Fax #:
Last name:*
Gant, Jr.
Street Address
1821 North Park Avenue
Address Line 2
City
State / Rovince / Fbgion
Burlington
NC
Fbstal / Zip Code
Country
27217
us
Shawmut Park Avenue LLC
Street Address
1821 North Park Avenue
Address Line 2
City
State / Rovince / Fbgion
Burlington
NC
Fbstal / Zip Code
Country
27217
us
e. Facility contact person (prior to change, optional):
First name: Middle name: Last name:
Andrea Saurage
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: Shawmut Park Avenue LLC
Conpany Nacre
c. Person to be legally responsible for permit:
First name:* Middle name: Last name:*
William McGowe
n
Title:
Permit holder's mailing address:*
Street Address
1821 North Park Avenue
Address Line 2
Oty
Burlington
Wstal / Zip Code
27217
Phone #:*
Email address:*
336-
WMcGow
221-
en@sha
2116
wmutcorp
oration.c
om
d. Faciltiy name:* Shawmut Park Avenue, LLC
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:*
Craig Wilson
Phone #:* 336-221-2220
Email address:* [e-mail]
State / Province / Plegion
NC
Country
us

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:*
Lauren Name: Lowe
Title:
Mailing Address:* Street Address
1821 North Park Avenue
Address Line 2
oty
Burlington
Fbstal / Zip Code
27217
Phone #:* 336-221-2152
Email Address:* [e-mail]
State / Rovince / Fbgion
NC
Country
us

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 (1) 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
FLrrrit-holder prior to the ownership change, or permt-hdder authorizing the narre change
Will another person need to complete or sign this form before it can be submitted? 11/o 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.lucas(a)ncdenr.gov.

Initial Review
Project ID: * Fbviewer may revise perrrit number here if incorrect.
NCG170242