NC0088170_Owner (Affiliation Change)_20210624

ROY COOPER w
Governor r
DIONNE DELLI-GATTI �✓
Secretary
S.DANIEL SMITH NORTH CAROLINA
Director Environmental Quality
PERMIT NAME/OWNERSHIP CHANGE FORM
I. CURRENT PERMIT INFORMATION:
Permit Number: NCO() 8 / 8 / 1 / 7 / 0 or NCG5 / / / /
1. Facility Name: Whispering Streams WWTP RECEIVED
II. NEW OWNER/NAME INFORMATION: ECC ED
1. This request for a name change is a result of:
iUN 2 4 2021
a. Change in ownership of property/company NCDEQ/DWR/NPDES
b. Name change only
X c. Other(please explain): Change of address and Contact Information
2. New owner's name(name to be put on permit):
3. New owner's or signing official's name and title: Ricky Hunsucker
(Person legally responsible for permit)
Facilities Manager
(Title)
4. Mailing address: 110 Bacage Drive City: Houma
State: LA Zip Code: 70360 Phone: (985) 257-0216
E-mail address: [e-mail]
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]
DENorth Carolina Department of Environmental Quality I Division of Water Resources
v 512 North Salisbury Street 11617 Mali Service Center I Raleigh.North Carolina 27699-1617
�Ia +v+a\� 919.707.9000

NPDES Name&Ownership Change
Page 2 of 2
Applicant's Certification:
I. Ricky J.Hunsucker , 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: Date: 6/a/40A/
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 11/2020