NC0040045_Owner (Affiliation Change)_20240510

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arli J' MICHAEL S. RECAN
LINDA CULPEPPER
Water Resources Imo imDirector
ENVIRONMENTAL QUALIFY
PERMIT NAly iO i NERSH P CHANGE FORM
I. 'CURRENT ERMiT i ORMAT1ON:
Permit Number: NCO() Ili 0/d / //l,5- or NCG5 / / / /
1. Facility Name: &/tc 7h'R �� C�Dp14 - to RECEIVED
NEW
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�I. fen v C.ivviae� aiP iviim INFORMATION:h p�(tV
4_ This r �.est-fcr .-.,am -..4.�,.,-ge-is..,-r.sulltcf: �VIHI
NCDEQIDWRINPDES
V a. Change in ownership of property/company
b. Name change only
c. Other(please explain):
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3. New owner's or signing official's name and title: Of,a,, ,®
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(Person legally responsible for permit)
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4: iviaiiing address: /,7/0 S 0)cyI€y'-, k'n a #city:_ L,'r/to d
State: 41(, Zip Code: d 7t 9 / Phone: (33(a ) 5 - */9'
E-mail address: r®0\r,3 e eoa.�o69i b 'Mi , i -
THIS APP i ir=ATInN o AC°' ACE VII! L NOT BE r C CFP I ED BY TH_ DIVISi`N IUNLESS-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)
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1.5CC reverse SiUC UI U lla IJca�.G lul s-igi IctLUI& requifemeI I,I. J
State of North Carolina I Environmental Quality{Water Resources
1617 Mail Service Center I Raleigh.NC 27699-1617
919 807 6300 919-807-6389 FAX
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NPDES Name&Ownership Change
Page 2 of 2
Applicant's Certification:
fO n�� ,� , 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 ail-required-supporting_inforrnation and attacnmenis are not included-, this application
package will be returned as incomplete.
Signature: Date: e ozy
T H'E COMPLETED APPLICA E lO ' 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 11/2017