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HomeMy WebLinkAboutNCS000259_Name-Owner Change Form_4/25/2019Action History (UTC-05:00) Eastern Time (US & Canada) Submit by Anonymous User 4/25/2019 7:54:33 AM (Name Change Submission) Approve by McCoy, Suzanne 6/10/2019 1:48:24 PM (Notification to Admin) • The task was assigned to McCoy, Suzanne 4/25/2019 7:54 AM � ST1V{ NORTH C:Ft iO�INA ErtYfranminlQf QYQiff}� I. Permit Information I. Please enter the permit number for which the change is requested. NPDES Stormwater Individual Permit #: NCS000259 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: AkzoNobel Surface Chemistry LLC Company Nlarre b. Person legally responsible for permit: First name:* Middle name: Last name:* William Teasdale Title: Site Operations Director Permit holder's mailing address:* Street Address 485 Cedar Springs Road Address Line 2 oty State / Rovince / Fbgion Salisbury NC Fbstal / Zip Code Country 28147-9249 us Phone #:* 704- 797- 5011 c. Facility name:* d. Facility address:* Fax #: AkzoNobel Surface Chemistry LLC Street Address 485 Cedar Springs Road Address Line 2 oty State / F rovince / Fbgion Salisbury NC Fbstal / Zip Code Country 28147-9249 us e. Facility contact person (prior to change, optional): First name: Middle name: Last name: 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: Nouryon Surface Chemistry LLC Corrpany Nacre c. Person to be legally responsible for permit: First name:* Middle name: Last name:* William Teasdale Title: Site Operations Director Permit holder's mailing address:* Street Address 485 Cedar Springs Road Address Line 2 aty Salisbury Wstal / Zip Code 28147-9249 Phone #:* Email address:* 704- william.te 797- asdale@ 5011 nouryon. com d. Faciltiy name:* Nouryon Surface Chemistry LLC Is the FACILITY contact different than the person legally responsible above?* r Yes f No f. Facility contact person: First name:* Middle name: Last name:* Chris Fleming Phone #:* 704-633-1731 ext. 6203 Email address:* christopher.fleming@nouryon.com State / Province / Pegion NC Country us IV. Permit Contact Information Is the PERMIT contact different than the person legally responsible above?* f• Yes r No IV. Permit contact information (if different form the person legally responsible for the permt) .................................................................................................................................................................................................... First Name:* Middle Last Name:* Chris Name: Fleming Title: Waste Management Supervisor Mailing Address:* Street Address 485 Cedar Springs Road Address Line 2 City Salisbury F bstal / Zip Code 28147-9249 Phone #:* 704-633-1731 ext. 6203 Email Address:* christopher.fleming@nouryon.com 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 (919) 707-3639 or e-mail Annette Lucas at annette.lucas(a)ncdenr.gov. Initial Review Project ID: * Pleviewer rray revise perrrit number here i incorrect. NCS000259