NCG551287_owner (name change)_20230626

ROY COOPERurnernor
UL,4�
EwLIZABETH S. BISERSc,�etar%
S. DANIEL SMITH
NORrll CAROLINA
Dhector
Environmental Quality
NPDES Certificate of Coverage (CoC}
NCG550000 OWNERSHIP CHANGE FORM
Please enter the CoC number for which the change is requested.
Certificate of Coverage
N I C I G 15 15
II. Please provide the following for the requested change (revised CoC).
a. Request for change is a result of ❑ Change in ownership of the residence/property
❑ Name change of the facility or owner
!f other please explain:
b. CoC will be issued to (person's name
or company name, if applicable):
c. Owner: person legally responsible for
CoC:
d. Facility name (if applicable):
Facility address:
f. Facility contact person:
[if different from Owner]
M vCD N Gtttt'� �n 1° 010- Die i
First MI Last
Title
S 3 1g n d ove t Q(:3
Permit Holder Mailing Address
Da hccwL fy a 9 7 7) a
City - -State Zip
( q/9) 6S5-62)9 % jeme-mdLey eamat,
Phone -mail Address
O Ct.
Address
cha.m No. a97/01
City State Zip
-First MI Last
r ) `� i
Phone E-mail Address
111. Contact person (if different from the person legally respon ible for the CoQ
First MI Last
Title
Mailing Address
City State Zip
Phone E-mail Address
Nortfr Cor'olina Dep:rrtmcn[ Quality Division of W ocr Rrsource5
m;�D_ E Q SQ North Solkbtir y Slreet 1617 %I Ail tiervice Center Rato(jh North (.ji olino 1i690 lbii
Onvrtr+.��ei rr.•onm�er Q+.�s,`. 4w", 914.707.n000

NCG550000 OWNERSHIP CHANCE FORM
Page 2 of 2
IV Will this permitted facility continue to discharge the same volume and type of wastewater as
prior to this ownership or name change?
Yes
❑ No (please explain)
V. Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS
ARE INCOMPLETE OR MISSING:
❑ This completed application is required for both facility -name change and. or facility ownership
change requests.
❑ Legal documentation of the transfer of ownership (such as a property deed, relevant pages of a
contract, or a bill of sale) is required for an ownership change request.
...................................................................................................................
The certifications below must be completed and signed by the new applicant in the case of an ownership
change request.
9cPLICAI T 1 ION
ttest h li lion for a name: ownership change has been reviewed and is accurate and
nplete to the best o any knowledge. I understand that if all required parts of this application are not
completed and that if all required supporting information is not included, this application package will be
returned as incomp 2 '2-5
Signature Date
PLEASE SEND THE COMPLETE APPLICATION PACKAGE TO:
Mr. Charles H. Weaver
NC DEQ I DWR NPDES
1617 Mail Service Center
Raleigh, NC 27699-1617
charles.weaver dncdenr.gov
L/ be 6 W 0 0�'

Durham County, NC Property Report 5131/2423
Parce'rnTo-rmation
PIN:
0825-49-02-0281
Parcel ID:
187730
Acreage:
0.672
Land Use:
RF5/ 1-FAMILY
Deed Book:
006547
Deed Page:
000356
Plat Book:
000051
Plat Page:
000053
Subdivision:
MILTON FRST SEC 5
Site Address:
530 ANDOVER RD
Owner Name:
MCDOWELL MYRON
Owner Address: 5.30 ANDOVER RD
Land Value:
$29,260.00
null
DURHAM NC 27712
Total Value:
$238,287.00
,
Building Value:
$209,027.00
Sale Price:
$175,000.00
Tax Maps are not to be used to establish boundaries and/or size. Use for such Is soley the repam b; ty of !fir use-.

N