NCG550708_Owner (Name Change)_20201119

ROY COOPER
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t.
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a MICHAEL S. REGAN
LINDA CULPEPPER
Water Resources Interim Owed'''.
ENVIRONMENTAL QUALITY
RECEIVED
PERMIT NAME/OWNERSHIP CHANGE FORM
NOV 19 2020
I. CURRENT PERMIT INFORMATION: NCDEQ/DWR/NPDES
Permit Number: NCO() / / / / or NCG55--/0 /7 /0/8
1. Facility Name:
' II. NEW OWNER/NAME INFORMATION:
1. This request for a name change is a result of:
1/-a. Change in ownership of property/company
b. Name change only
c. Other(please explain):
2. New owner's name (name to be put on permit):
SUSAN D WILLIS and AUSTIN C WILLIS / I,
3. New owner's or signing official's name and title: �c,�ti.. 4 0,4,(41
(Person legally responsible for permit)
(Title)
4. Mailing address: 118 HOWARD VAUGHAN RD City: ROUGEMONT
State: NC_ Zip Code: 27572 Phone: (336) 364-0641
E-mail address: sdswillisqmail.com
THIS APPLICATION PACKAGE WILL NOT BE ACCEPTED BY THE DIVISION UNLESS ALL OF THE
APPLICABLE ITEMS LISTED BELOW ARE INCLUDED WITH THE SUBMITTAL.
REQUIRED ITEMS:
1. This completed application form
2. Legal documentation of the transfer of ownership (such as a property deed, articles of
incorporation, or sales agreement)
[see reverse side of this page for signature requirements]
State of North Carolina I Environmental Quality I Water Resources
1617 Mail Service Center I Raleigh,NC 27699-1617
919 807 6300 919-807-6389 FAX
https://deq.nc.gov/about/d iv i sions/water-resources/water-resources-permits/wastewater-branch/npdes-wastewater-perm its

NPDES Name&Ownership Change
Page 2 of 2
Applicant's Certification:
I, rt� _ /L_L /S. , attest that this application for a
name/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 and that
if all required supporting information and attachments are not included, this application
package will be returned as incomplete.
Signature: j,t,e;:, /42 </1.Jitl:16.:, Date: 2/7 e-d
THE COMPLETED APPLICATION PACKAGE, INCLUDING ALL SUPPORTING
INFORMATION & MATERIALS, SHOULD BE SENT TO THE FOLLOWING ADDDRESS:
NC DEQ / DWR / NPDES
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Version 11/2017

PLA T rp _ts
MAP Fife No 19N211
Case No 18-'&6-122r530
Borrower Susar 0 Willis
Property Address_ 118 Howard Vaughan Road
CAy Ro.gerront Coin _ Person State NC Zip Code 27572-7064
Lender/gent Wets Fargo Bank,NA1 Dept orVA Address 27)1 Wells Fargo Way-MAC X9901-04A,Minnepotis,MN 55426
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