NC0089265_Owner Affiliation Change_20180628

ROY COOPER
Clove)no,
. MICHAEL S. REGAN
Sect ciao,
LINDA CULPEPPER
W
Intel 102()imam
ENVIRONMENTAL QUALITY
PERMIT NAME/OWNERSHIP CHANGE FORM
CURRENT PERMIT INFORMATION:
Permit Number: NC00 $ / /lv / 5 or NCG5 / / / /
1. Facility Name Dobson VV T 12
II. NEW OWNER/NAME INFORMATION:
1. This request for a name change is a result of:
RECEIVED/DENR/DWR
a. Change in ownership of property/company
V b. Name change only JUN 2018
Water Resources
c. Other(please explain)• Permitting Section
2 New owners name (name to be put on permit).
Laura 11. N �e {
3. New owners or signing official's name and title. LC.(..t a 14-
(Person legally responsible for permit)
n Mai/Amor
(Title)
4 Mailing address. P O. 6(,v- 361 City. Damon
State:NC. Zip Code 2701-1 Phone: (SS(o ) 351.0- iv2
E-mail address: Law a. rllQiv@ do ors - ry
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.nc.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, Lau*a 14 . N ttl , 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: gtAAACA 1i1.114-al Date: Le I -Le 12018
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