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HomeMy WebLinkAboutNCS000566_Name-Owner Change Form_6/9/2020 (2)Action History (UTC-05:00) Eastern Time (US & Canada) Submit by Anonymous User 6/9/2020 9:02:46 PM (Name Change Submission) Approve by McCoy, Suzanne 6/11/2020 8:54:41 AM (Notification to Admin) • The task was assigned to McCoy, Suzanne 6/9/2020 9:02 PM NORTH CAROLINA EmlmnmerrW Quality I. Permit Information I. Please enter the permit number for which the change is requested. NPDES Stormwater Individual Permit #: NCS000566 NC SX XX XX X -OR- General Permit Certificate of Coverage (COC) #: 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: Lester Development Corporation Cor pany f brre b. Person legally responsible for permit: First name:* Middle name: Last name:* George M Dickens, Jr. Title: President & CEO Permit holder's mailing address:* Street Address P. O. Drawer 4991 Address Line 2 C ly State / Rovince / Fbgion Martinsville Virginia Fbstal / Zip Code Country 24115 United States Phone #:* Fax #: 276- 276- 656- 632- 3257 2117 c. Facility name:* Fortress Wood Products d. Facility address:* Street Address 3874 Bethel Dr Exd Address Line 2 C ly State / Rovince / Fbgion High Point NC Fbstal / Zip Code Country 27260 US e. Facility contact person (prior to change, optional): First name: Middle name: Last name: Pete Haskins Phone #: 336-854-9585 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:* Lester Development Corporation Conpany fine c. Person to be legally responsible for permit: First name:* Middle name: Last name:* George M Dickens, Jr. Title: President & CO Permit holder's mailing address:* Street Address P. O. Drawer 4991 Address Line 2 city State / Province / Region Martinsville Virginia Fbstal / Zip Code Country 24115 United States Phone #:* Email address:* 276- jdickens 656- @lesterg 3257 roup.com d. Faciltiy name:* Fortress Wood Products 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:* Pete Haskins Phone #:* 336-854-9585 Email address:* phaskins@fortresswood.com IV. Permit Contact Information Is the PERMIT contact different than the person legally responsible above?* r Yes No IV. Permit contact information (if different form the person legally responsible for the permit) First Name:* Middle Last Name:* Pete Name: Haskins Title: Plant Manager Mailing Address:* Street Address 3874 Bethel Dr Exd Address Line 2 City State / R'ovince / Region High Point NC Fbstal / Zip Code Country 27260 Us Phone #:* 336-854-9585 Email Address:* phaskins@fortressvvood.com 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 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. In addition, I agree that submission of this form is a "transaction" subject to Chapter 66, Article 40 of the NC General Statutes (the "Uniform Electronic Transactions Act"); and I agree to conduct this transaction by electronic means pursuant to Chapter 66, Article 40 of the NC General Statutes (the "Uniform Electronic Transactions Act"); Permittee Signature ter% W dicsrr. cAt- Perait-holder prior to the ownership change, or pernit-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 (919) 707-3639 or e-mail Annette Lucas at annette.lucas(a)ncdenr.gov. Initial Review Project ID:* Pleviewer may revise permt nurrber here if incorrect. NCS000566