NC0058815_Owner (Affiliation Change)_20211104

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FERMJT NAM EIO N E RSH IP CHANGE FORM
I. CURRENT PERFIf INFORMATION!
Permit Number_ NC fl4 5 / ; j , k 1 or NCOS�'If
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II_ NEWOWNER/NAME INFORMATION:
T. This regui%[ fora name change is rruft oF.
Chang in owrIership I properrikAriVarly
. Name change only
5.c Other (pICY�se exp�,ir,) r"+a�! }► Cti po+� + . L c V (, J c rk
2. New owru name (nOmc to be put en p+er]n4
3. New °voles or Signing offic691' name and II k
(Per$(011 !Wally resportiSiblc for permit)
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(Title)
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Tin APPLICATION PACKAGE WILL N DT RE ACCEPTrr} BY THE DIIVL ION UNLESS E5S ALL OF THE
APPLICABLE ITEM$ LISTED I3EI flitY J' KE FNCI LJ r] F n WFTI I THE SUBMITTAL
REQUIRED ITEMS:
1 _ This completed applic itiorr bun
2_ Legal documentation of the 1ansfer of ownership ( t,iCti as a property deed, articiks of
incorporation, or sales agreemerrf)
[sod reverse side of !his pa a kw signature requiremcriaq
SIA90 41r Ninth Carobs I Enxiomnenul1 !iL I Water Rewigai.
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Page 2 of 2
APplicarst's CertiE cation_
i
I,...pk tilt_ 1rrio , attest that this application for a
nimefownership change has been reviewed and is aor sale and complete Ito the first .of my
knowledge_ 1 w derstand !hat if alI required parts of this application are not completed and that
if all required Supporting information and attachments are not included, Uiis appiical iron
package will be returned as irrcornpleIe,
Signature! `- Date: k a
TFIE COMPLETED APPLICATION PACKAGE, INCLUDING ALL SUPPORTING
INFORMATION & MATERIALS, SHOULD BE SENT TO THE FOLLOWING ADDDRESS:
NC DEQ J1 DWID'INFt NPDES
1G17 Mail Srwice Center
Raleigh, North Carolina 2 7699-1617
Ver M n 11/2017