NCG060364_Wayne-Sanderson Farms Name Change_20251015

WAYNE . s 0
TOGETHER,WE G
Q ®��
Certified Mail No: 7021 2720 0000 4464 9770P���e��G
October 2, 2025 0����5���
DEMLR Stormwater Program
512 North Salisbury Street, 6th Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 2699-1612
Re: Wayne Farms LLC and Sanderson Farms LLC name change
Effective 1/1/2026, the name on stormwater permits for Wayne Farms LLC and Sanderson
Farms LLC will change to Wayne-Sanderson Farms LLC. Enclosed are the original NPDES
Stormwater Permit Name Change/Ownership Change forms for our locations.
This is effective 1/1/2026.
Any questions, please feel free to call me at 601-426-1572 or email
step hanie.shoemakeraAwavnesanderson.com .
Thanks,
jqw P %W"Uo'z�
Stephanie Shoemaker
Sr. Director of Environmental
Wayne-Sanderson Farms LLC
4110 Continental Drive, Oakwood, Georgia 30566 800.392.0844 waynesandersonf arms.com

NORTH CAROLINA
Department_of_the Secr_etary_of_State
To all whom these presents shall come, Greetings:
I, ELAINE F. MARSHALL, Secretary of State of the State of North Carolina, do hereby
certify the following and hereto attached to be a true copy of
APPLICATION FOR CERTIFICATE OF AUTHORITY
OF
WAYNE-SANDERSON FARMS LLC
the original of which was filed in this office on the 24th day of September, 2025.
IN WITNESS WHEREOF,I have hereunto set my
hand and affixed my official seal at the City of
Raleigh,this 24th day of September,2025.
Scan to verify online.
Certification#C202526602171-1 Reference#C202526602I71-1 Page:I of Secretary of State
Verify this certificate online at htips•I/www.sosne.gov/verification

I
J SOSM:3141368
s' Date Filed:9/24/2025 7:40,00 AN
_ Elaine F.MorshaLL I _
North CmUaa Secretary or I State
SYaaa ojNarm Carolina C2025 266'02171
Depatbnedi of theSeeMary ofState
APPLICATION FOR CERTIFICATE OF AIITSORITy
FOR LIMITED LIABILITY COMPANY
Pmsnamt to WD 7.03.of.the Oeaged Statutes of
Notth Carolina-0te tmdarelgoet1limited co
ib
Cetitfidete ofAtnhorlty brommot business in the State of Norm CamUna,and for that purpose scuba th;lb o�g lies for a
1. fheaameofibeMiitedliablilycotnmis'WaynesaadasoaFowLW
and Ifthe Hmlted I(ability Company name is neavafiable.for use in the State ofNorth Caroffna,the npme the limited
liability company wishes to aso is
2. The state oaeountrytnderwhose Iewr the limited Iia8lifty company was fbtmed is Delawmo
3. Principal office imfomamfioa: (Se(ead eithera or b.)
a ®The Pmdted llabluty comp vhas a principal office.
17leprigoipal offtce telephone Mm&w 7702973457
The street address and county of the principal office of4u limited liabilitywmpany,is;
Nucabor and Street:4110 Coadneand Drive
Oakwood Stater Zip Code:30566 Counry, Hall
The mailing address,tjd[p"ermpom Mesteet address,of the principal office oftlu.empmation is:
Number and Street
Cftr- Stetx' Zip Code; Coonw.
b. ❑The'ltmited liability company does sot have apriaeipal office.
4. The name of the registered agent in the State ofNo&Caroffna m C Tt:mpoiatioa System
5. The street address and county of the mgiateted agent•e office in tbo State of North'Cmolina is:
Nmtber and Street 160 Mme Luke Ct.,Ste.200
Ral*
Cib- h' State NC Zip Code27__L.17 Coumy Warm
6. Tha North Carolinu mailing addms,ifd jferent fmm thc.*ed addrar,ofAe regiskrad egeat's of c6.in the.State of North
Camime is:
Number'and Sheet
Store NC Zip Code: Cow;
,
BUSINESS REGISTRATION DIVISION P.O.BOX 29622
(RavLmdJu ,2ot� RALEIGH,NC 27626-0622
(Form 149)
rrcmr.tuara wefmlmv,rMWe
Certl gtlon1i C20252$¢02171-1 RgfgrAgqe#C20252660217I-Page:2 of 4

J •
y ' .
! APPLICAUON'FOR CERT]nCA=OFAUMOMW i
Page2
7. The Damao,
mao ndwooujtu tu+ossnddmssasoftbeegnreateOMMofficWsoftlu .)38b11i1yCq>SpgpgNa '
.� ^"!JJ(`IiW'dDCI0AF111BILL,rb..t+&n.ab,.aQ.rsao.zw df.,wM 7.J
Nmne art r
Jeremy IOlbpm,Odef Legal and Compllann officer
4110 Continental Drive,Oakwood,OA 3D566
------------
a. -Attachedh ogeustpdyfliadtedllabIltflento of teooe(ordocumentotsimil�rlmP�bdalYauthenticetedbythesMstaryofatate orDamot$eW
tY mPanYtewrdsierhodateOrwentryoflbrmatton TbeCerlllicalenr7+:iae e_ .�_
Iessthansiemoatbeotd. An6etawevartM>...wn.,.w._
- gagtha aceoehd
9. JftbeltmhedliabilitycOmpanyLSmplimdtansaa6ctidOwIuaejaordertob= Mbudnessintbis3
resolutica of ita managms adoptiegthe 6c6tious acme is attached tato, copy ofthe
10.(C0004:Pleesepmvido a business e�m7 addsen.
The SeaemryefSl ate's Once will a rsailthebusfm=5 automatieaUyatthe addlessprOvided aboveetno cosevken adacnmant
is((itd. 0 6aL Muldod 911_.aa__.:. l i � � ebsibe. ForIUM IMmUflyon once this service Is o
the tnstruoboos farthis duo®ant >IY f[e[ed,please see
11.Tlds applieafionvat!be e$eectiva ppoa Hung,mless a delayed date and/ortime is specified
Thisthe4deyof—yet 2D
WaYneSsadersonParms LLC
TRIM, oil mrtedLfabrllry Compaay
idta<1 .
Ietemy V.Kiibnm Chief Legal and Compliance Officer
i 7ypa orPrrnrxam{,a and Title
Raw. T
I. TM9feels•SZ50.-Thls document muctbegedvAth the 3ecteteryofSt"
BUSMMS REGISTRATION DrvisioN P.O.BOX 296U
(Rerrredlgry70J7) RALEIGH,NC27626.0622
(Farm L09)
tamr.unrmn sine,sk.m ow.
'--Certirientfantr C202526602171.1 Reference#C202526602171 Page-3 of 4

Delaware Pagel
The First State
S1 =RUM SECRETARY OF STATE OF 2w STATE
OF DEWOMM, DO HEREBY MUTZY -RAM—SANDERSON rAMIfS LLC" IS DVLY
EIOmm UNDER THE LAWS OS THE STATE 08 DELAWARE AND IS TN GOOD•
r STA M3NG AND HAS A LEGAL EXISTENCE SO EAR AS XM RECORDS OF THIS
OFFICE SHOW, AS or THE TWENTY—EIGHTH DAY OF AUGUST, A.D. 2025.
`• AND S DO REREHY b'DRTSER CERTIFY THAT THE ANWAL TARES RAVE EIEEN
JI PAIJ3 TO DATE.
i
r
,
}
CMnWPNRm rem■h•L S•■ntery•TSLt•
6096052 8300 Authentle'ation:204603220
SR420253818706 Date:W29-25-
You mayve"thts cettl@ate online at wrp.delaware,8ov/autMeeshtml
*Certificatiatio'C=326602t7l-I,Rchrence#C20 21 1-P e:4of4

�-- • NORTH CAROLINA
Depar-tment-of-tie-Secretary of State
CERTIFICATE OF AUTHORITY
L ELAINE R MARSHALL, Secretary of State of the State of North Carolina, do he eby
certify that
WAYNE-SANDERSON FARMS LLC
having filed on this date an application conforming to the requirements of the Gen,ral
Statutes of North Carolina, a copy of which is hereto attached, is hereby grante
authority to transact business in the State ofNorth Carolina.
o m IN WITNESS WHEREOF,I have hereunto set
' my hand and affixed my official seal at the City
of Raleigh,this 24th day of September,2025.
�y Sean to verify online.
Document Id:C202526602171 Secretary of State
Verifythis certificateordineathttps:tAvwwsomc.gov/ved-rication-- -

.des SiNr a.
NC DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF Energy, Mineral, and Land Resources
'�aabYMa'` STORMWATER PROGRAM
NORTH CAROLINA
Environmental Quality
NPDES STORMWATER PERMIT NAME/OWNERSHIP CHANGE FORM
I. CURRENT PERMIT INFORMATION:
Permit Number: NCS���_/_/_ or NCG 0
1. Facility Name(prior to change): r-q Mr v (-(7e T:�ed M t(f
II. NEW OWNER/NAME INFORMATION:
2. This request for a name change is a result of:
a. Change in ownership of property/company
Xb. Name change only(Facility and/or Company)
c. Other(please explain):
(for example,facility address update. Include additional attachments if necessary.)
3. New owner's name(name to be put on permit as Permittee):
w�tY�-e ' Ski(Licht�Gtl�h�s UDC�
4. New owner's or signing official's name and title:h( 1 17A ino] kcj
(Person legally resp nsible for permit)
1(iViC �-q , yl7Y Wr\1 I
(Ti )) r
5. Mailingaddress: �t� ,��II `''vffU Ciity: tA`Jl ,, I � L �,l
State:`� Zip
1 Code: NL( n Phone: ( W (") 1/ f' _ �' 0 N
E-mail address�I(tl i �k(Ilik& al �rv�i b&60" , Coo-- 1
6. New facility name(if applicable):� �� J� �t�v (t� f
7. Effective date of transfer or name change: ( O
I ( I 2A0
D_ North Carolina Department of Environmental Quality I Division of Energy.Mineral and Land Resources
E QJ
512 North Salisbury Street 1 1612 Mail Service Center I Raleigh,North Carolina 2 769 9-1612
919.707.9200

NPDES Stormwater Permit Name/Ownership Change
Page 2 of 2
Ill. PERMIT AND FACILITY CONTACT INFORMAATTIIO,,N�/,v1 /� C na
8. New permit contact's name and title: �iC/I✓' `�f I�,L v�w�
(Permit Contact)
, 1�1�Pct'ue- ��tin 1�rclZt 1
(Title) p/� f
9. Mailing address: �yslV " t�0 City: w �(( ��`
State: Zip Code: J Phone:
E-mail address"/IWJNylila , �hyy"G1,,-1e
10. New facility contact's name and title:
(Facility Contact)
L y D� Mc ✓
(Title)
11. Mailing address: `�"NJ i1 ��✓✓����YfffAAt �� `� W/l�f City: /��CJ
State:/ Zip Code:2�Jt/ 1 Phone: " -8 I�1 �kS-L
E-mail address: yX(1.K6ue- tyh
12. New billing contact's name:V`An ILe ShWf��
(Billing Contact)
13. Mailing address: D VO ` City: t Vl lit
Stater /� Zip Code \ Phones: ( U(D
E-mail address:�t,f b(Z(11�6 �Yl fY�E P�I� clyVS4t1ttelS6Y\.c� 1�
IV. FACILITY ACTIVITIES AND DISCHARGE INFORMATION
1. Will industrial activities at the facility remain the same as under the previous owner?
Yes�$No❑ }},
2. Will the stormwater discharge location(s) remain the same? Ye VV�L_No ❑
NOTE: If either of these questions is answered"No,"then more information is needed to review
the request. Please attach documentation to describe and explain the changes to the facility
activities, stormwater discharges, and/or outfall location. Depending on the information
provided, the Division may require that the new owner file a new permit application.
Last Revised 3/13/2022

NPDES Stormwater Permit Name/Ownership Change
Page 2 of 2
THIS APPLICATION PACKAGE WILL NOT BE ACCEPTED BY THE DIVISION UNLESS
ALL OF THE ITEMS LISTED BELOW ARE INCLUDED.
REQUIRED ITEMS:
1. This completed application form (with original signature)
2. Legal documentation of transfer of ownership(such as relevant pages of a deed or a bill of sale) is
required for an ownership change request.Articles of incorporation are not sufficient for an
ownership change but can be provided for a name change.
3. Information to document facility,industrial activities,stormwater discharges,or outfall changes
as noted in item IV above (if appropriate)
Why is this information needed?
Regulations in 40 CFR§122.63 allow for minor modifications to NPDES permits for a change of
ownership or operational control of a facility, provided that information supports that no other change
in the permit are necessary.
Why does this form need to be mailed in?
Permittees and applicants must fulfill signatory requirements in the NPDES federal
regulations in 40 CFR §122.22 (please see those regulations for guidance). Until NCDEQ's
electronic submission process meets Cross-Media Electronic Reporting (CROMERR)
requirements, this original signed (not digital signature) form must be mailed to the
address below. The uploaded copy is stored as part of the permit record in the Division's
digital repository.
Applicant's Certification:
I, 1 vl,k ((`l attest that the application for a name and/or ownership
change submitted h s be 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 package will be considered
incomplete and may be returned.
o � zr
Signature: �_ Date:
THE COMPLETED APPLICATION AND ALL SUPPORTING INFORMATION SHOULD BE SENT TO:
DEMLR Stormwater Program
512 North Salisbury Street, 61'' Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
Last Revised 3/13/2022

NC DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF Energy, Mineral, and Land Resources
+..
$TORMWATER PROGRAM
NORTH CAROLINA
Environmental Quality
NPDES STORMWATER PERMIT NAME/OWNERSHIP CHANGE FORM
I. CURRENT PERMIT INFORMATION: /_ Q
Permit Number: NCS����_/ or
N(C�G�tk_(D I_v/5
1. Facility Name(prior to change): &yx)n
II. NEW OWNER/NAME INFORMATION:
2. This request for a name change is a result of:
a. Change in ownership of property/company
b. Name change only(Facility and/or Company)
c. Other(please explain):
(for example,facility address update. Include additional attachments if necessary.)
3. New owner's name(name to be put on permit as Permittee):
r
4. New owner's or signing official's name and title: Faw( ` ��(n 51e1 ,
(Person legally resp6risibLelcir permit)
OMIWWI" � d-�inv(fMwrctAI
(� ( E� ' /(.T tIee))
5. Mailing address: l IUyy����� City: LG(lL-t/ef
State: N6 Zip Code: 144q Phone: ( &(D I )trr/ l�
E-mail address:�l . �1��11'1(6k 1�.�.J ry 4�6n, l�1_
6. New facility name (if applicable):W kO4n SIAN ,O(`S uuc —fib G
7. Effective date of transfer or name change: Izzaa
D_E QJ� North Carolina Department of Environmental Quality I Division of Energy,Mineral and Land Resources
512 North Salisbury Street 1 1612 Mail Service Center I Raleigh,North Carolina 27699-1612
sal: .1�-� 919.707.9200

NPDES Stormwater Permit Name/Ownership Change
Page 2 of 2
III. PERMIT AND FACILITY CONTACT INFORRMMAITIIO,Nf. v
8. New permit contact's name and title:✓t�il'lY A nua SbWW(C ✓
(Permit Contact)
Srl p((kt,4:�ro(-grv�,gywryf dz,
(Title)
9. Mailing address: �' V `�0 W City: (���/f �1
State:� ^Zips Code: ✓ i 4 Phone: ( �t ) -1�
E-mail address: 34Q AbiY)6f4 9 Cif Mk Ue-E VN n
10. New facility contact's name and title: TL r ern �Wl(
(Facility Contact) n n!
(Title) 1_
11. Mailing address: ` �• �� ✓� J City: 7'/(�✓
State: '(��1 L /Zip Code: ' 0 Ff- ' Phone: (70)0 )
E-mail address: r�G���Ll
12. New billing contact's name: V
\1 Billing Contact)
a I /I
13. Mailing address: �. r✓U� i0 City:
/�1/
Stater Zip Code: Lm Phone: ( W1
E-mailaddresse—k ( Yllp Sheemu{ L�l(t.11P ( tsr �
IV. FACILITY ACTIVITIES AND DISCHARGE INFORMATION
1. Will industrial activities at the facility remain the same asunder the previous owner?
Ye4d_No ❑
2. Will the stormwater discharge location(s) remain the same? YeV No ❑
NOTE: If either of these questions is answered"No,"then more information is needed to review
the request. Please attach documentation to describe and explain the changes to the facility
activities, stormwater discharges, and/or outfall location. Depending on the information
provided, the Division may require that the new owner file a new permit application.
Last Revised 3/13/2022

NPDES Stormwater Permit Name/Ownership Change
Page 2 of 2
THIS APPLICATION PACKAGE WILL NOT BE ACCEPTED BY THE DIVISION UNLESS
ALL OF THE ITEMS LISTED BELOW ARE INCLUDED.
REQUIRED ITEMS:
1. This completed application form (with original signature)
2. Legal documentation of transfer of ownership(such as relevant pages of a deed or a bill of sale) is
required for an ownership change request.Articles of incorporation are not sufficient for an
ownership change but can be provided for a name change.
3. Information to document facility, industrial activities,stormwater discharges,or outfall changes
as noted in item IV above (if appropriate)
Why is this information needed?
Regulations in 40 CFR§122.63 allow for minor modifications to NPDES permits for a change of
ownership or operational control of a facility, provided that information supports that no other change
in the permit are necessary.
Why does this form need to be mailed in?
Permittees and applicants must fulfill signatory requirements in the NPDES federal
regulations in 40 CFR §122.22 (please see those regulations for guidance). Until NCDEQ's
electronic submission process meets Cross-Media Electronic Reporting (CROMERR)
requirements, this original signed (not digital signature) form must be mailed to the
address below. The uploaded copy is stored as part of the permit record in the Division's
digital repository.
Applicant's Certification:
I, a(.t l( attest that the application for a name and/or ownership
change submitted has been eviewed 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 package will be considered
incomplete and may be returned. /L�
Signature: �i/ma&/ Date: 194/ �
THE COMPLETED APPLICATION AND ALL SUPPORTING INFORMATION SHOULD BE SENT TO:
DEMLR Stormwater Program
512 North Salisbury Street, 6"' Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
Last Revised 3/13/2022

CY NC DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION of Energy, Mineral, and Land Resources
''►awl' STORM WATER PROGRAM
NORTH CAROLINA
Environmental Quality
NPDES STORMWATER PERMIT NAME/OWNERSHIP CHANGE FORM
I. CURRENT PERMIT INFORMATION:
Permit Number: NCS_/��� / or NCG
1. Facility Name (prior to change): ✓YnS�L�
II. NEW OWNER/NAME INFORMATION:
2. This request for a name change is a result of:
a. Change in ownership of property/company
:. Name change only(Facility and/or Company)
c. Other(please explain):
(for example,facility address update. Include additional attachments if necessary.)
3. New owner's name(name to be put on permit as Permittee):
WUune - nd�� �rn5
4. New owner's or signing official's name and title:
(Person legally re onsibl for permit)
�Q, y I (/Tiit ef
5. Mailing address: Y-0�C�� //100 City: LAOre,( /L
State: r Zip Code:3( "I" Phone: (
E-mail address:�/ �t ( r bl�l({71,�I cLd114-
6. New facility name(if applicable)
: li(� �Q(�Sl� -
7. Effective date of transfer or name change: �zz Zrrw
North Carolina Department of Environmental Quality I Division of Energy.Mineral and Land Resources
512 North Salisbury Street 1 1612 Mail Service Center I Raleigh,North Carolina 27699-1612
919.707.9200

NPDES Stormwater Permit Name/Ownership Change
Page 2 of 2
III. PERMIT AND FACILITY CONTACT INFORMATION
'•
8. New permit contact's name and title:
/ (Permit Contact) n�
Jf
(Title) II ////
9. Mailing address:Y•O , _ � +� 1A(
/I City: -
State:l )S //-- Zip Code: lI� '�°"� Ph�oynn�e: (
E-mail address. 111(�N.
10. New facility contact's name and title:
(Facility Co�nta�ctt)�,
�Q (Title) t ,�
11. Mailing address: V0(/�/��''/�\�✓ V —X7 7 City:
State:�l/ Zip Code: LZ o Phone: ( Jit—�(Q)
E-mail address: rW�\� l o(�
12. New billing contact's name..
(Billing Contact)
13. Mailing address: t ' `r✓U� /,f�`b City:
State:� //��'��Zip Code.30q�_ Phone:
E-mail address:7l(1 k(A n (e ' ShWthoto---P '__ - ne13
IV. FACILITY ACTIVITIES AND DISCHARGE INFORMATION
1. Will industrial activities at the facility remain the same as under the previous owner?
YeA No ❑
2. Will the stormwater discharge location(s) remain the same? YeoNo ❑
NOTE: If either of these questions is answered"No,"then more information is needed to review
the request. Please attach documentation to describe and explain the changes to the facility
activities, stormwater discharges, and/or outfall location. Depending on the information
provided, the Division may require that the new owner file a new permit application.
Last Revised 3/13/2022

NPDES Stormwater Permit Name/Ownership Change
Page 2 of 2
THIS APPLICATION PACKAGE WILL NOT BE ACCEPTED BY THE DIVISION UNLESS
ALL OF THE ITEMS LISTED BELOW ARE INCLUDED.
REQUIRED ITEMS:
1. This completed application form (with original signature)
2. Legal documentation of transfer of ownership(such as relevant pages of a deed or a bill of sale) is
required for an ownership change request.Articles of incorporation are not sufficient for an
ownership change but can be provided for a name change.
3. Information to document facility, industrial activities,stormwater discharges,or outfall changes
as noted in item IV above(if appropriate)
Why is this information needed?
Regulations in 40 CFR§122.63 allow for minor modifications to NPDES permits for a change of
ownership or operational control of a facility, provided that information supports that no other change
in the permit are necessary.
Why does this form need to be mailed in?
Permittees and applicants must fulfill signatory requirements in the NPDES federal
regulations in 40 CFR §122.22 (please see those regulations for guidance). Until NCDEQ's
electronic submission process meets Cross-Media Electronic Reporting (CROMERR)
requirements, this original signed (not digital signature) form must be mailed to the
address below. The uploaded copy is stored as part of the permit record in the Division's
digital repository.
Applicant's Certification:
I, attest that the application for a name and/or ownership
change submitted has bee 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 package will be considered
incomplete and may be returned.
Signature: A`/_4/ Date:
THE COMPLETED APPLICATION AND ALL SUPPORTING INFORMATION SHOULD BE SENT TO:
DEMLR Stormwater Program
512 North Salisbury Street, 61' Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
Last Revised 3/13/2022

NC DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF Energy, Mineral, and Land Resources
STORMWATER PROGRAM
NORTH CAROLINA
Environmema/Quality
NPDES STORMWATER PERMIT NAME/OWNERSHIP CHANGE FORM
I. CURRENT PERMIT INFORMATION:
Permit Number: NCS__J__/__/__/_/_ or NCGOII � ICY, j—z—� n
1. Facility Name (prior to change): "_a C/-{�IK40A OI; LIBr 5 1 Va
II. NEW OWNER/NAME INFORMATION: J
2. This request for a name change is a result of:
_a. Change in ownership of property/company
_41b. Name change only (Facility and/or Company)
c. Other(please explain):
(for example,facility address update. Include additional attachments if necessary.)
3. New owner's name (name to be put on permit as Permittee):
�� - `�r.1V1�P,✓��bY� `TGtr�ns U.���/,(C�,/ rr !` p
4. New owner's or signing official's name and title: '"`u ` ?(•Ll����'V-o''c-"I
P(Person legally r pons a for permit)
V1 o y,V�InS-k-
(Tifle)
1
S. Mailing address: �• l �U 0 City: �/ ee
State: Zip Code:
I(� Phone:
E-mail address(.-AL(., (Ll({�yl��wl(""il�cf(�QP�(1t2i61�F(6VI�
6. New facility name (if applicable):wEiNt"7S6(NSAV�`�A YriS UC
7. Effective date of transfer or name change:
D_E Q� North Carolina Department of Environmental Quality I Division of Energy.Mineral and Land Resources
512 North Salisbury Street I Ib12 Mail Service center I Raleigh,North Carolina 2 769 9-1612
02m:eaa�i-....a...-.e,•.x.+,� 919.707WOO

NPDES Stormwater Permit Name/Ownership Change
Page 2 of 2
III. PERMIT AND FACILITY CONTACT INFORMATION
8. New permit contact's name and title: v,� (P
(Permit Contact)
p Q �i (Title) /� r
9. Mailing address: \ �o tl . e City:
State: 9�) Zip
� Code:�� Phhoonle•:/((00(
E-mail adds:, J resk(�(/y�,&L O , CiV M((lQu�u �
10. New facility contact's name and title: JCi�ed VvW'e
(Facility Contact)
� L
C/. (Title) Y�
11. Mailing address: O'Cok City:
State: Zip Code: n Phone:
E-mail address: Q Lowe ("� �11�AttY�b�/ItJIfGYI . Y\
12. New billing contacts namel
Q (}, N (Billing Contact) f� �/
13. Mailing address: ` '� \N� (�(��av City: '-& e� c
Stater c' .�Ziip Code: `"l �j�P�h���one: ((,gol ))L(W —( >
E-mail address �k/, "nie• 5��,f ! li49 ry g1YH/K6\,Al
IV. FACILITY ACTIVITIES AND DISCHARGE INFORMATION
1. Will Li dustrial activities at the facility remain the same as under the previous owner?
Yes ICI No ❑
2. Will the stormwater discharge location(s) remain the same? Yes)] No ❑
NOTE: If either of these questions is answered"No,"then more information is needed to review
the request. Please attach documentation to describe and explain the changes to the facility
activities,stormwater discharges, and/or outfall location. Depending on the information
provided, the Division may require that the new owner file a new permit application.
Last Revised 3/13/2022

NPDES Stormwater Permit Name/Ownership Change
Page 2 of 2
THIS APPLICATION PACKAGE WILL NOT BE ACCEPTED BY THE DIVISION UNLESS
ALL OF THE ITEMS LISTED BELOW ARE INCLUDED.
REQUIRED ITEMS:
1. This completed application form (with original signature)
2. Legal documentation of transfer of ownership (such as relevant pages of a deed or a bill of sale) is
required for an ownership change request.Articles of incorporation are not sufficient for an
ownership change but can be provided for a name change.
3. Information to document facility, industrial activities,stormwater discharges,or outfall changes
as noted in item IV above(if appropriate)
Why is this information needed?
Regulations in 40 CFR§122.63 allow for minor modifications to NPDES permits for a change of
ownership or operational control of a facility, provided that information supports that no other change
in the permit are necessary.
Why does this form need to be mailed in?
Permittees and applicants must fulfill signatory requirements in the NPDES federal
regulations in 40 CFR §122.22 (please see those regulations for guidance). Until NCDEQ's
electronic submission process meets Cross-Media Electronic Reporting (CROMERR)
requirements, this original signed (not digital signature) form must be mailed to the
address below. The uploaded copy is stored as part of the permit record in the Division's
digital repository.
Applicant's Certification:
I, , attest that the application for a name and/or ownership
change submitted has b 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 package will be considered
incomplete and may bee returned. {
Signature: G�f Date: 2/
THE COMPLETED APPLICATION AND ALL SUPPORTING INFORMATION SHOULD BE SENT TO:
DEMLR Stormwater Program
512 North Salisbury Street, 61h Floor(Office 6401K)
1612 Mail Service Center
Raleigh, NC 27699-1612
Last Revised 3/13/2022

ydNh 4
p' NC DEPARTMENT OF ENVIRONMENTAL QUALITY
_ DIVISION OF Energy, Mineral, and Land Resources
STORMWATER PROGRAM
NORTH CAROLINA
Environmental Qualiry
NPDES STORMWATER PERMIT NAME/OWNERSHIP CHANGE FORM
I. CURRENT PERMIT INFORMATION:
Permit Number: NCS__/__/__/ ylS ut �( r 17our NCG_g _j�Jy*2-1
�r 1. Facility Name(prior to change):SkW M' � t'` po Tom"' (,At((
ll. NEW OWNER/NAME INFORMATION:
2. This request for a name change is a result of:
a. Change in ownership of property/company
4b. Name change only(Facility and/or Company)
c. Other(please explain):
(for example,facility address update. Include additional attachments if necessary.)
3. New owner's name(name to be put on permit as Permittee):
VJ(k�he— tr�d��h�-errs LLL- ( �B
4. New owner's or signing official's name and title:R" y��{�j�jiG(/I
` (Person legally r pons' a for permit) y,
VC' 111 u"l��f(I��i�'�1�✓IWfI'YNOh��t/�
I ('T.itle)
p
5. Mailing address: \ to•� II / City: l�G'W,/let ( 'f_
State: Zip Code:�1�— Phone: ( bt( ) l f w
E-mail address: WAUA, bklliho�Sle�
6. New facility name (if applicable): he—
7. Effective date of transfer or name change:
North Carolina Department or Environmental Quality I Division of Energy,Mineral and Land Resources
[J/+'�`rR Q 512 North Salisbury street 1 1612 Mail Service Cemer I Raleigh.North Carolina 2 769 9-1612
919.707.9200

NPDES Stormwater Permit Name/Ownership Change
Page 2 of 2
Ill. PERMIT AND FACILITY CONTACT INFORMATION \
8. New permit contacts name and title: AOWy o �Y 1ee(YyuLef
(Permit Contact)
�QQ (Title)
9. Mailing address: �/� City:
State: y,Z,ippCCocle:f" L44 Phones: ( (M )424'( 5 D'
E-mail address:��L0(\wA e. Qi9e(Y1({,�CA�(r �1 �V\ S(trKteS(j_\ kyy--
10. New facility contact's name and title:
(Facility Contact)
l�v P C�CQ 4A5tl uns r-
(Title)
11. Mailing address: I rn� "`��� VvVu� City:
State:—k(/ ' /Zip Code: I , Phonee: (�'Jp�) 1Y1
E-mail address: W�i t V\ (n'^) W 411e S('1-' n y;on , cw-\
12. New billing contacts name: (P S�I
/�(} (Billing Contact)
13. Mailing address: �IJY/U� U City:
State: 'V '� ZipCode�'4Cf Phone:
E-mail address:� 0
IV. FACILITY ACTIVITIES AND DISCHARGE INFORMATION
1. Will industrial activities at the facility remain the same asunder the previous owner?
Ye#�No ❑
2. Will the stormwater discharge location(s) remain the same? Yeo-No ❑
NOTE: If either of these questions is answered"No,"then more information is needed to review
the request. Please attach documentation to describe and explain the changes to the facility
activities,stormwater discharges, and/or outfall location. Depending on the information
provided, the Division may require that the new owner file a new permit application.
Last Revised 3/13/2022

NPDES Stormwater Permit Name/Ownership Change
Page 2 of 2
THIS APPLICATION PACKAGE WILL NOT BE ACCEPTED BY THE DIVISION UNLESS
ALL OF THE ITEMS LISTED BELOW ARE INCLUDED.
REQUIRED ITEMS:
1. This completed application form (with original signature)
2. Legal documentation of transfer of ownership(such as relevant pages of a deed or a bill of sale) is
required for an ownership change request.Articles of incorporation are not sufficient for an
ownership change but can be provided for a name change.
3. Information to document facility, industrial activities,stormwater discharges, or outfall changes
as noted in item IV above(if appropriate)
Why is this information needed?
Regulations in 40 CFR§122.63 allow for minor modifications to NPDES permits for a change of
ownership or operational control of a facility, provided that information supports that no other change
in the permit are necessary.
Why does this form need to be mailed in?
Permittees and applicants must fulfill signatory requirements in the NPDES federal
regulations in 40 CFR §122.22 (please see those regulations for guidance). Until NCDEQ's
electronic submission process meets Cross-Media Electronic Reporting (CROMERR)
requirements, this original signed (not digital signature) form must be mailed to the
address below. The uploaded copy is stored as part of the permit record in the Division's
digital repository.
Applicant's Certification:
I, & ` � , attest that the application for a name and/or ownership
change submitted ha-"keen r viewed 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 package will be considered
incomplete and may be returned.
Signature: / �— Date:
THE COMPLETED APPLICATION AND ALL SUPPORTING INFORMATION SHOULD BE SENT TO:
DEMLR Stormwater Program
S12 North Salisbury Street, 6t' Floor(Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
Last Revised 3/13/2022

NC DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF Energy, Mineral, and Land Resources
�'�w«w►' STORMWATER PROGRAM
NORTH CAROLINA
Environmental Quality
NPDES STORMWATER PERMIT NAME/OWNERSHIP CHANGE FORM
I. CURRENT PERMIT INFORMATION:
Permit Number: NCS__/__/ (��� /_ or NCGLU 7J /�5 �A—
l. Facility Name(prior to change)�kr*
II. NEW OWNER/NAME INFORMATION:
2. This request for a name change is a result of:
a. Change in ownership of property/company
_D�. Name change only(Facility and/or Company)
c. Other(please explain):
(for example,facility address update. Include additional attachments if necessary.)
3. New owner's name(name to be put on permit as Permittee):
e ors �Gt(rYts,
4. New owner's or signing official's name and title:lLLw� �I��(1�(1Slefn
(Person legally respon ible for permit)
�l'P���r�,�f1a ��nvt I'1�(1ryYG1'�G✓I
( �j ( Itle)
5. Mailing address: C�7•�t�/D IW City:UVA0 ' 1
State: v Zip Code: 3N4l Phone: ( U0 I )(M
E-mail address.-V(L ,fh1��1
6. New facility name(if applicable):1 JL,,Y\l--A1 w"iAft� LLL —
7. Effective date of transfer or name change:Tl�u0
��� North Carolina Department of Environmental Quality I Division of Energy,Mineral and Land I esountxs
512 North Salisbury Street 1 1612 Mail Service Center I Raleigh,North Canahna 2 769 9-1612
919.707.9200

NPDES Stormwater Permit Name/Ownership Change
Page 2 of 2
Ill. PERMIT AND FACILITY CONTACT INFORMATIOII,^N!! I ne�.n�"
8. New permit contact's name and title: 1 lyl n 5f ly �t U r
(Permit Contact)
!6 1Cnvwv~w
(Title) II pp,, A
'' 11//np��
9. Mailing address: � •� r✓l2)� (�1 City:
\L-ew �—y
State:i v`i Zip Code:J 1 I Phone: ( Gol ) `T Ya
E-mail address:5�Yll(. GJh�'f�(ti(CG�t�`-dwyV_gj( P6(aA
10. New facility contact's name and title:-T 5�e Pi`� (Facility Contact)
Cft(eK fV I`46 r�
�
_ ,r I (Title
11. Mailing address: N Il I w �`l�� �"�1 ap wesJ City: 5�,VaL,L(S State:�� Zip Code:de Phone: (&0 ( )3I0 'Z ( I u
E-mail address Oepl , . evkn5 61r ,rVs4r (;0-\ ,t of�
12. New billing contact's name: n�Pe�
p (Billing Contact)13. Mailing address: C 0,� (/�, City 1 , '
�,L�1
State:M� Zip
'Code m4c _ Phone: ( �I ) f NO (S��
E-mail address. YpIW I Pi 5Y 1� e✓(fl 4` tf SGt/LlP/5r5Y1 .f 14
IV. FACILITY ACTIVITIES AND DISCHARGE INFORMATION
1. Will inilustrial activities at the facility remain the same as under the previous owner?
YesNo ❑
2. Will the stormwater discharge location(s) remain the same? Yevk No ❑
NOTE: If either of these questions is answered "No,"then more information is needed to review
the request. Please attach documentation to describe and explain the changes to the facility
activities, storm water discharges, and/or outfall location. Depending on the information
provided, the Division may require that the new owner file a new permit application.
Last Revised 3/13/2022

NPDES Stormwater Permit Name/Ownership Change
Page 2 of 2
THIS APPLICATION PACKAGE WILL NOT BE ACCEPTED BY THE DIVISION UNLESS
ALL OF THE ITEMS LISTED BELOW ARE INCLUDED.
REQUIRED ITEMS:
1. This completed application form (with original signature)
2. Legal documentation of transfer of ownership(such as relevant pages of a deed or a bill of sale) is
required for an ownership change request.Articles of incorporation are not sufficient for an
ownership change but can be provided for a name change.
3. Information to document facility, industrial activities,stormwater discharges,or outfall changes
as noted in item IV above(if appropriate)
Why is this information needed?
Regulations in 40 CFR§122.63 allow for minor modifications to NPDES permits for a change of
ownership or operational control of a facility, provided that information supports that no other change
in the permit are necessary.
Why does this form need to be mailed in?
Permittees and applicants must fulfill signatory requirements in the NPDES federal
regulations in 40 CFR §122.22 (please see those regulations for guidance). Until NCDEQ's
electronic submission process meets Cross-Media Electronic Reporting (CROMERR)
requirements, this original signed (not digital signature) form must be mailed to the
address below. The uploaded copy is stored as part of the permit record in the Division's
digital repository.
Applicant's Certification:
I, (,l �) % , attest that the application for a name and/or ownership
change submitted Ins bee 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 package will be considered
incomplete and
may be returned.
Signature: /� Date: ® �
THE COMPLETED APPLICATION AND ALL SUPPORTING INFORMATION SHOULD BE SENT TO:
DEMLR Stormwater Program
512 North Salisbury Street, 61h Floor(Office 640K)
1612 Mail Service Center
Raleigh, INC 27699-1612
Last Revised 3/13/2022

d� W
A,
NC DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF Energy, Mineral, and Land Resources
W
`la,,,,>• STORMWATER PROGRAM
NORTH CAROLINA
Environmental Quality
NPDES STORMWATER PERMIT NAME/OWNERSHIP CHANGE FORM
I. CURRENT PERMIT INFORMATION: ((,�,
Permit Number: NCS_/���_/_ or 1NCG���� /`�
1. Facility Name(prior to change):Wf n Ted M L(<
II. NEW OWNER/NAME INFORMATION:
2. This request for a name change is a result of:
a. Change in ownership of property/company
_oLb. Name change only(Facility and/or Company)
c. Other(please explain):
(for example,facility address update. Include additional attachments if necessary.)
3. New owner's name (name to be put on permit as Permittee):
kJ( ne - SA()J-a���U(ens I L
4. New owner's or signing official's name and title:
' ff (Peerrso`n�legally rA ponsi e�ffor permit) y,
VQ' a �'IY1Pe'�1� � Lh�l fmtY�Gtvty�1
Q y jQ� I (Titre)
5. Mailing address: �'�' `�� `�� City: IOW'A�1(e
I r 'J r c
State: CC Zip Code: 3644 I I/I,Phone:
E-mail address:`,�MA�_. ,�CTkWr\,949MMOO (Wk,
6. New facility name(if applicable)II4.IVIP'�tl ( 1 '� S �Lk/ Kin _-ee
A I
7. Effective date of transfer or name change:
D North Carolina Department of Environmental Quality I Division of Energy.Min"and Land Resources
[JJ� 512 North Salisbury street 1 1612 Mail Service center I Raleigh,North Carolina 27699-1612
919.707.9200

NPDES Stormwater Permit Name/Ownership Change
Page 2 of 2
III. PERMIT AND FACILITY CONTACT INFORMATION /1 [�j�� r�
8. New permit contact's name and title, QY�G1rtLto31QIr 'wF'�✓
(Permit Contact)
(Title)
9. Mailing address: F-6, 'mil)��� City:
State::J Zip Code?:✓ '� Phone:
E-mail address64-,- 7Mftt>a ! 16Lrr ��✓�?.I, ,nr r f�rM , c
10. New facility contact's name and titles epmq r✓t)W�(F
Facility Contact)
Cam,
D ()y '�/� (Title) (�7 �,/�<l_
11. Mailing address: l -9i✓V�=?(�� City:�YU2""�./Ulr"!\ 2 y
State: ] pZiipp Code: (��V t Phone:
E-mail address:
12. New billing contact's name—awhi51,1 h Ma4t Y
((jj.am�, 7( (Billing Contact) II //','' II��
13. Mailing address: & ?&i It/t� City: LAP
Stater Zip
__Cl!ode: Phone: ( (�b� ) Ao
E-mail address` !J{'llt � ! �7�CC/I! wy' mry,ca(wei,-6� ,( y�-,
IV. FACILITY ACTIVITIES AND DISCHARGE INFORMATION
1. Will industrial activities at the facility remain the same asunder the previous owner?
Yes
P4o ❑
2. Will the stormwater discharge location(s) remain the same? Yeso-No ❑
NOTE: If either of these questions is answered "No,"then more information is needed to review
the request. Please attach documentation to describe and explain the changes to the facility
activities, stormwater discharges, and/or outfall location. Depending on the information
provided, the Division may require that the new owner file a new permit application.
Last Revised 3/13/2022

NPDES Stormwater Permit Name/Ownership Change
Page 2 of 2
THIS APPLICATION PACKAGE WILL NOT BE ACCEPTED BY THE DIVISION UNLESS
ALL OF THE ITEMS LISTED BELOW ARE INCLUDED.
REQUIRED ITEMS:
1. This completed application form (with original signature)
2. Legal documentation of transfer of ownership(such as relevant pages of a deed or a bill of sale) is
required for an ownership change request.Articles of incorporation are not sufficient for an
ownership change but can be provided for a name change.
3. Information to document facility,industrial activities,stormwater discharges, or outfall changes
as noted in item IV above (if appropriate)
Why is this information needed?
Regulations in 40 CFR§122.63 allow for minor modifications to NPDES permits for a change of
ownership or operational control of a facility, provided that information supports that no other change
in the permit are necessary.
Why does this form need to be mailed in?
Permittees and applicants must fulfill signatory requirements in the NPDES federal
regulations in 40 CFR §122.22 (please see those regulations for guidance). Until NCDEQ's
electronic submission process meets Cross-Media Electronic Reporting (CROMERR)
requirements, this original signed (not digital signature) form must be mailed to the
address below. The uploaded copy is stored as part of the permit record in the Division's
digital repository.
Applicant's Certification:
I, , V�(^ IG , attest that the application for a name and/or ownership
change submitted ha bee viewed 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 package will be considered
incomplete and may be returned.
Signature: j�i �_ Date: /6�
THE COMPLETED APPLICATION AND ALL SUPPORTING INFORMATION SHOULD BE SENT TO:
DEMLR Stormwater Program
512 North Salisbury Street, 6`" Floor(Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
Last Revised 3/13/2022