NC0043320_Legally Responsible_20161027

PAT MCCRORY
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, Gov,?rnor
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DONALD R. VAN DER VAART
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Water Resources S. JAY ZIMMERMAN
ENVIRONMENTAL QUALITY T7/rL'txOY
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PERMIT NAME/OWNERSHIP CHANGE FORM
I. CURRENT PERMIT INFORMATION:
Permit Number: NC00/3 /j / a / O or NCGS_/_/_/_/_
1. Facility Name: > c rr, t PIA T
II. NEW OWNER/NAME INFORMATION: RECEIVEMCDEQUA
1. This request for a name change is a result of:
= OCT 2 7 2016
Slater Quality
a. Change in ownership of property/company Permitting Sedion
b. Name change only
V /0_0�TntT
fic. Other (please explain): Duincf- 0e_`-' n
2. New owner's name (name to be put on permit):
3. New owner's or signing official's name and title: C Ox
(Person legally responsible for permit)
PO
(Title
4. Mailing address: ` O � fix asD City: COrcko %) VA
State: Zip Code: a(�337 Phone: (c116 ) Ll 1 `7 -
E-mail address: C-01 Cox g6bc3, . G0+'l/\
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
https://deq.ne.gov/about/divisions/water-resources/water-resources-permits/wastewater-branch/npdes-wastewater-permits

NPDES Name & Ownership Change
Page 2 of 2
Applicant's Certification:
I, �gAJp IJ (%o k , 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. Y
Signature: G� Date:
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 712016