NCS000312_Name-Owner Change Form_7/16/2018

Environmental
Quakry
I. Permit Information
I. Please enter the permit number for which the change is requested.
NPDES Stormwater Individual Permit #:
NCS000312
NC
sx
xx
xx
x
-OR-
General Permit Certificate of Coverage (COC) #:
NC
CDC
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: Dart Acquisitions, LLC
Corrpany Wre
b. Person legally responsible for permit:
First name:* Middle name: Last name:*
Erik Bomireto
Title: President
Permit holder's mailing address:*
Phone #:*
70439
59559
c. Facility name:*
d. Facility address:*
Fax #:
Street Address
4132 Pompano Road
Address Line 2
aty
Charlotte
Fbstal / Zip Code
28216
State / Province / Fbgion
NC
Country
USA
DART Acquisitions, LLC - Charlotte Facility
Street Address
4132 Pompano Road
Address Line 2
aty
Charlotte
Fbstal / Zip Code
28216
e. Facility contact person (prior to change, optional):
First name:
Phone #:
Middle name: Last name:
State / Province / Fbgion
NC
Country
USA

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:* AERC Acquisition Corporation d/b/a DART, A Clean
Earth Company
Conpany Narre
c. Person to be legally responsible for permit:
First name:* Middle name: Last name:*
Bernard Guerin
Title: VP/Secretary/Treasurer
Permit holder's mailing address:*
Street Address
334 South Warminster Road
Address Line 2
city
Hatboro
F%stal / Zip Code
19040
Phone #:* Email address:*
21573 bguerin
41400 @cleane
arthinc.c
om
State / Province / Felgion
PA
Country
USA
d. Faciltiy name:* AERC Acquisition Corporation d/b/a DART, A Clean
Earth Company
e. Facility address:* Street Address
4132 Pompano Road
Address Line 2
aty
State / Province / Fbgion
Charlotte
NC
Fbstal / Zip Code
Country
28216
USA
Is the FACILITY contact different than the person legally responsible
above?
r Yes
r No
f. Facilitycontact person:
First name:* Middle name: Last name:*
Erik Bomireto
Phone #:* 7043959559
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 perrrit)
...................................................................................................................................................................................................................
First Name:*
Middle Last Name:*
Cheryl
Name: Coffee
Title:
Director of Environmental & Compliance
Mailing Address:*
Street Address
334 South Warminster Road
Address Line 2
oty
State / Rovince / Fbgion
Hatboro
PA
F bstal / Zip Code
Country
19040
USA
Phone #:* 6097312906
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.
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:* Wload supporting docurrentation for ownership change
Signed Transfer Agreement.pdf 1.36MB
pdr 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
s1604"Izv
F2rrrit-holder prior to the ownership change, or permit -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
r f .
To w horn 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 Laura
Alexander at [phone] or e-mail her at [e-mail].

Initial Review
Project ID:* NCS000312