HomeMy WebLinkAboutSW6100804_Permit Information Update Form_20220425STATE STORMWATER:
PERMIT INFORMATION UPDATE APPLICATION FORM APR 2 5 2022
There is NO FEE for updating project name or permittee information. DEMLR
This form is to only to be used by the current permittee to notify the Division of.- Fayetteville regional
9) changes to the Point of Contact (signing official) for the current permittee (LLC, Corporation, HOA or POA);
2) changes to the mailing address, phone number or email address of the current permittee;
3) changes to the name of the project, and
4) changes to the legal corporate name as documented by a Name Change or Merger filed with the NCSOS.
A. NEW PERMIT INFORMATION
State Stormwater Permit Number: SW6100804
Are you updating
(check all that apply):
If so, please provide the updated information:
❑ Project name
❑ Corporation Name'
® Permit Contact Name2 ,3
Martin D Koon
® Permit Contact Title
Manager/Member
❑ Mailing Address3
❑ Phone number
❑ Email address
Provide documentation such as a Name Change / Merger filed with the NCSOS.
Provide supporting documentation such as NCSOS filing. The permit contacts position must be in accordance
with 15A NCAC 02H .1040(1).
If more than one point of contact or mailing address is being changed, please attach a separate sheet.
B. CERTIFICATION OF PERMITTEE
I, Martin D Koon , the current permittee, hereby notify DEMLR that I am making the
changes as listed in Sectio A above. I further attest that this application for an update to the permit information currently
on file is accurate � om e e e s f y knowledge.
Signature: �' Date: y 22- `® 20 C
Eso i.( /LY , a Notary Public for the State ofWor4A (24,ry l ; fi c -i
County of Y V I I K-eS , do hereby certify that P / l C (7HV b k0 b/),
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persgt�Wytetp!ppy�red before me this the day of ( 20, and acknowledge the due
e` kr0Dt f�oing instrument. Witness my hand and official seal,
County
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Stormwater Permit Information Update Form Page 1 of 1 May 11, 2017