NCG560058_owner name change_20210309

ROY COOPER
MICHAEL Sr REGAN
S, DANIEL SMITH
rr.,
NORTH CAROLINlA
Enrironmenraf Quality
PERMIT NAME/OWNERSHIP CHANGE FORM
{ [ RRENT PERMIT INFORMATION:
Permit Number: NCflllfi1_l or NCG5 10/ 0/5/It
1. Facility Name: N0(01 C O/011 i OPp+' 0 11'cl� hvra, t Co+ J r
I. NEW OWNER/NAME INFORMATION: SertiCLJ
1. This request for a name change is a result of:
a. Change in ownership ofprnpertyfcompany
Kb. Name change only
c. Other (please explain):
New owner's name (name to be put on permit):
1�l'Sb 8 J/aii+yt ( t )o ev Owl ' JAt )
3. New owner's or signing official's name and title: At 1 r s II Y1 e ra114 vi
(Person legally responsible or permit)
(Title)
4. Mailing address: if b (A tp4411 re f..tr (e City: it r`Q
State: AA" Zip Code: 710 9 f —lobo Phone: ( 9?') (1111
E-mail address:
r Ills APPLICATION PACKAGE WILL NOT BE ACCEPTED BY THE DIVISION UNLESS ALL OF
l ILL APPLICABLE ITEMS LISTED BELOW ARE INCLUDED WITH THE SUBMITTAL.
REQUIRED [TEMS:
l . This completed application form
?. Legal documentation of the transfer of ownership (such as a property deed, articles of incorporation,
or sales agreement)
[set: reverse side of this page for signature requirements]
iat93
North Carolina Deaarment of Environmental Quality I Dirr51411 0} Water ResalrC€5
1617 Marl Service Center • Ralaig#r. North Carolina 27699.1617
919-707-900A

NPDES Name & Ownership Change
Page 2 of 2
Applicant's Certification:
1, 1{,/"t v a / lak.7 , attest that this application for a
namelowncrship change has been mewed and is accurate and complete to the best of my knowledge. l
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.
THE COMPLETED A 'CATION PACKAGE, INCLUDING ALL SUPPORTING
INFORMATION & MATERIALS, SHOULD BE SENT TO THE FOLLOWING ADDDRESS:
NCDEQIDWR!NPDES
1617 Mail Service Center
Raleigh. North Carolina 27699-1617
Version 11i2020