NC0049867_Owner (Affiliation Change)_20200103

ROY COOPER
Governor
Y,. MICHAEL S. REGAN
`.' Sectetaty
LINDA CULP
Water Resources EC i11 e
ENVIRONMENTAL QUALITY
3
PERMIT NAME/OWNERSHIP CHANGE FORM JAN ' 2020
I. CURRENT PERMIT INFORMATION: NCDEQI®WRINP®ES
Permit Number: NCO() q / g/ 7/ 7 or NCG5 / / / /
1. Facility Name: I oak) 0-f i f eve/ it a to t 11
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 r
N./ c. Other(please explain): (1.`�(�(1GP in re_spo l51 We - rI I oc I on f y
2. New owner's name (name to be put on permit): /
3. New owner's or signing official's name and title
(Person legally responsible for permit)
f�J (Tie) ,, /
4. Mailing address. -PC OK_ 4a9 City. C ie I (Cr ci
State' k/e.— Zip Code' cl'7O () Phone: ('7c4) -4-7/7/
E-mail address: (r Ie\e(CLvl deieL 'i nct no, ©r3
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, c--f-frir h?12 f , 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 s inc. plete.
Signature: � Date: /,aF/O/y
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