DEQ-CFW_00007645

CURRENT PERMIT INFORMATION:
Permit Number: NCOO or
INFORMATION:1. Facility Name:
NEW OWNERMAME
request1. This - change is a result •
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):
3. New owner's or signing official's name and title:
4. Mailing address:
State: Zip Code:
E-mail address:
PAT MC C,RORY
DONALD R. VAN DER VAART
S. JAY Z1MMLRMAN
kF U1 JVII IUVCIIIY IUOVVI IJIVIG IVI [JUI II IIL]
(Title)
City:
Phone: ( )
1. This completed application f•
2. •.l do e• of of ownership property deed, of
incorporation, or agreement)
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:Hdeq.nc.gov/about/divisions/water-resources/water-resources-pernrits/wastewater-branch/npdes-wastewater-permits
DEQ-CFW 00007645

NPDESName & Ownership Change
Page 2nf2
attest that this application for a
name/ownership change has been reviewed and is accurate and complete to the best of my
!,�nowledge. 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
#ackage will be returned as incomplete.
1617 Mail Service Center
'J"XIaleigh, North Carolina 27699-1611
VecSion7/JO16