NC0030139_owner (name change)_20240624

ROY COOPER
Governor
ELIZABETH S. BISER
se<retoiy
RICHARD E. R,OGERS, JR.
NORTH CA.ROLINA
Environmental Quality
PERMIT NAME/OWNERSHIP CHANGE FORM
I. CURRENT PERMIT INFORMATION:
Permit Number: NC00 3/ 0/ 1 / 3 / 9 or NCG5 / / / /
1. Facility Name: Hilltop Health and Rehabilitation
II. NEW OWNER/NAME INFORMATION:
1. This request for a name change is a result of:
a. Change in ownership of property/company
b. Name change only
c. Other (please explain):
2. New owner's name (name to be put on permit):
Rutherfordton NC Opco LLC
3. New owner's or signing official's name and title:
4. Mailing address:
State: N C
188 Oscar Justice Road
Wesley Summerlin
(Person legally responsible for permit)
Admin
(Title)
City: Rutherfordton
Zip Code: 28139-8110 Phone: ( 828 ) 2863-9001
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]
North Carolina Department ofEnvtronmentalQuality l Division of Water Resources
'2A Q 512 North Salisbury Street 11617 Mail Service Center I Raleigh, North Carolina 27699-1617 ;_//
919.707.9000

Page 2 of
Applicant's Certification:
I, Wesley Summerlin , 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: /z, L-i /z,
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, NC 27699-1617