HomeMy WebLinkAboutNCS000155_Name-Owner Change Form_7/1/2019Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 7/1/2019 3:43:10 PM (Name Change Submission)
Approve by McCoy, Suzanne 7/8/2019 3:04:38 PM (Notification to Admin)
• The task was assigned to McCoy, Suzanne 7/1/2019 3:43 PM
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I. Permit Information
I. Please enter the permit number for which the change is requested.
NPDES Stormwater Individual Permit #:
NCS000155
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: GKN Sanford
Company Nlarre
b. Person legally responsible for permit:
First name:* Middle name:
Last name:*
Charles
Corwin
Title:
Site Director
Permit holder's mailing address:*
Street Address
4901 Womack Road
Address Line 2
oty
State / Rovince / Fbgion
Sanford
NC
Fbstal / Zip Code
Country
27330
us
Phone #:*
919-
708-
4510
c. Facility name:*
d. Facility address:*
Fax #:
Gkn Sanford
Street Address
4901 Womack Road
Address Line 2
oty
State / F rovince / Fbgion
Sanford
NC
Fbstal / Zip Code
Country
27330
us
e. Facility contact person (prior to change, optional):
First name: Middle name: Last name:
Christop Blaine
her
Phone #: 910-751-1718
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: GKN Sanford
Corrpany fibre
c. Person to be legally responsible for permit:
First name:* Middle name: Last name:*
Charles Corwin
Title: Site Director
Permit holder's mailing address:*
Street Address
4901 Womack Road
Address Line 2
Oty
Sanford
Wstal / Zip Code
27330
Phone #:* Email address:*
919- charles.c
708- orwin@g
4510 knautom
otive.com
d. Faciltiy name:* GKN Sanford
Is the FACILITY contact different than the person legally responsible
above?*
r Yes
f No
f. Facility contact person:
First name:*
Christop
her
Phone #:*
Middle name
910-751-1718
Last name:*
Blaine
Email address:* christopher.blaine@gknautomotive.com
State / Rovince / Fbgion
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:*
Christop Name: Blaine
her
Title: EHS Specialist
Mailing Address:* Street Address
4901 Womack Road
Address Line 2
City
Sanford
Fbstal / Zip Code
27330
Phone #:* 910-751-1718
Email Address:* christopher.blaine@gknautomotive.com
State / F 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 (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 (919) 707-3639 or e-mail Annette Lucas at annette.lucaslcDncdenr.gov.
Initial Review
Project ID: * Reviewer rray revise perrrit number here i incorrect.
NCS000155