NCG590022_Other_20240719

ROY COOPER
Governor
MICHAEL S. REGAN
Secretary
LINDA CULPEPPER
Water Resources Intenm Director
ENVIRONMENTAL QUALITY
PERMIT NAME/OWNERSHIP CHANGE FORM
I. CURRENT PERMIT INFORMATION:
Permit Number: NCOO / / / / or NCG5 9 / 0 / 0 / 2 / 2
1. Facility Name: Pender County Wastewater Treatment Plant
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
X c. Other(please explain):Change in responsible official only
2. New owner's name (name to be put on permit): Michael Silverman
3. New owner's or signing official's name and title: Michael Silverman
(Person legally responsible for permit)
Pender County Manager
(Title)
4. Mailing address: PO Box 5 City: Burgaw
State: NC Zip Code:28425-0995 Phone: [phone]
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]
State of North Carolina I Environmental Quality I Water Resources
1617 Mail Service Center I Raleigh,NC 27699-1617
919 807 6300 919-807-6389 FAX
hops://deq.nc.goy/about/divisions/water-resources/water-resources-permits/wastewater-branch/npdes-wastewater-Permits

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NPDES Name&Ownership Change
Page 2 of 2
Applicant's Certification:
I, Michael Silverman 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: 7/if1Z(j
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, North Carolina 27699-1617
Version 11/2017