NC0073571_Owner (Affiliation Change)_20190716

ROY COOPER
Governor
1MIICHAEL S. REGAN
Secrelaly
LINDA CULPEPPER
Water Resources interim Director
ENVIRONMENTAL QUALITY
PERMIT NAME/OWNERSHIP CHANGE FORM
I. CURRENT PERMIT INFORMATION:
Permit Number: NC0073571
1. Facility Name: Countryside Manor WWTP
II. NEW OWNER/NAME INFORMATION:
RECEIVED/NODEQ/®WR
1. This request for a name change is a result of:
a. Change in ownership of property/company JUL 1 6 2019
b Name change only Water Quality
Permitting Section
_X_c. Other(please explain) Change in personnel
2. New owner's name (name to be put on permit):
3. New owner's or signing official's name and title. Todd Nunn
(Person legally responsible for permit)
President
(Title)
4. Mailing address: 77
a v (AS / ( SAS City. 0*(604.
State.e0C Zip Code: ;73Sr 7 Phone: ( 134 ) 4#3 6 3v(
E-mail address:+SO cc?,w,x 's 6_c re", c 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/abo ut/divisions/water-resources/water-resources-permits/wastewater-branch/npdes-wastewater-permits

NPDES Name&Ownership Change
Page 2 of 2
Applicant's Certification:
I, Todd Nunn _ _, 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: -17/r2/11
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
1
Version 11/2017