NCG050141_Name-Owner Change Form_2/28/2019

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 2/28/2019 11:20:52 AM (Name Change Submission)
Approve by McCoy, Suzanne 2/28/2019 12:22:32 PM (Notification to Admin)
* NCG050141
• The task was assigned to McCoy, Suzanne 2/28/2019 11:20 AM

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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) #:
NCG050000
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: Coveris Fle)ables US LLC
Conpany�Jane
b. Person legally responsible for permit:
First name:* Middle name:
Last name:*
Reggie
Goldsmit
h
Title:
General Manager
Permit holder's mailing address:*
Street Address
1308 Blair st
Address Line 2
aty
State / Rovince / Fbgion
Thomasville
NC
Fbstal / Zip Code
Country
27360
United States
Phone #:* Fax#:
33647
4412
c. Facility name:* Coveris Fle)ables US LLC
d. Facility address:* Street Address
1308 Blair st
Address Line 2
aty State / Rovince / Fbgion
Thomasville NC
Fbstal / Zip Code Country
27360 United States
e. Facility contact person (prior to change, optional):
First name: Middle name: Last name:
Johnny L Welch
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: Transcontinental TVL LLC
Corrpany Nacre
c. Person to be legally responsible for permit:
First name:* Middle name
Helm
Title:
Permit holder's mailing address:*
Last name:*
Hansen
Street Address
1308 Blair st
Address Line 2
Oty
Thomasville
Postal / Zip Code
27360
Phone #:* Email address:*
33647 helm.han
44412 sen@tc.t
c
d. Faciltiy name:* Transcontinental TVL LLC
Is the FACILITY contact different than the person legally responsible
above?*
r Yes
f No
f. Facility contact person:
First name:*
Johnny
Phone #:*
Middle name
3364744406
Email address:* [e-mail]
Last name:*
Welch
State / Province / Fbgion
NC
Country
United States

IV. Permit Contact Information
Is the PERMIT contact different than the person legally responsible
above?
f Yes
r No

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 (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
Fbrrrit-holder prior to the ownership change, or permt-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 [phone] or e-mail Annette Lucas at annette.lucaslcDncdenr.gov.

Initial Review
Project ID: * Fbviewer may revise perrrit number here if incorrect.
NCG050141