NCG551431_application_20200113

4
NCDENR
North Carolina Department of Environment and Natural Resources
OlvielDn of Water Rmurree
Pat Mccn3ry Donald R.van der Vaart
WATER QUALITY PERMITTING SECTION swfty
PER11+1 U NAMEJOWNER5H&CHANGE UQM"
This form is for ownership changes or frame changes of NPDES wastrwattr permits.
+ "Pennittee" reference,,the exiling perink Molder
■ "Applicant"references the-esitity applyjag for the owncrshi Innme e* e,
L NPDES Permit No.(for which the chmoge b requcrred): N C U Q
or
Certireaae of Coverage#: N C G 5 5 13 I
IL Existing Permistet Information:
a. Permit issued to(oompany name):
b. Person tepity re5ponsfle for permit: fared RCs2ick
First MI Last
Title
130B rr-F1 [-XQ6-q-- O
Permit Holder WHimg Addrm
N C— ZS�
City Sft Zip
Phone Fax
c. Facility mate: 437 Nerthside Dr
d. )Facility's physical address: 437 Notthside Dr
Addrm
Cbspel MI NC 27516
City Sri zip
e. Facility contact persart_
First / NH 1 Last Phone
Ill. Applicant Information:
a Request fbr dha a is a rwutt of: Change in ownership of the f cility
Name change of the 6614 or owner
Yotber pleare explain:
b. Permit issued to(company name): Green River Properties,Inc-
u. Person legally reeponsibls for permit_ Floreneio Gonzalez
First M1 Last
Owner
Title
4301 Bennett Memor16 Rd
Fermft Holder h►Wlmg A,ddmw - —
Durhwn NC 27705-
city state zip
919 697-1537 f l9 'ciC�ud.00m
Phone E-mail Addmm
Pkm I a12 gybed 7AIM14

d. Facility name: 437 NordW&1r
e. Facility's physical o0mm- 437 NortUde Dr
Addr=
Opal Hill NC 27516r
city State 4
t l:aciliv crlgtad person: 1~loiendo Gonzalez
rim W Lmt
Owner
TiOc
919 697-1537 fgp 19 kW.c:oin
Phone E-mail Addresa
IV. Will tic periled heft coatiaae to to adoet the saris adhitks eaadtret�prior bs
this frwoership or nme dtaM?
® Yes
❑ No(p6m Wlaio)
If applicable,the applicant shall submit a major permit modification request to DWI.A me*modification Ad bo
defined as one that increasers the volume,increases the pol lutant land,remits in a sigtu5otstt rekadon of the
&&Barge point,or results in a change in the characteristics of the wade gaharatod.
Y. Aehialaed Items: TITtS APPLICATION WILL OF,RETURNM UNMOCEMD IF xI'EMIS ARE
INCO11+IPLETE OR MISSING:
t. This oompkied application is requL-W for bath name dhange andfar vwwrship change roquesa.
Z Legal doaumanla<iim of the transfer of ownaship(such as mlcvam pages of a contract load,or a bill of sale)is
rtmakrW for an ownetsltip change request. Articles of incorporation are not sufficieaht for an ownaship ChEw-
Applicable regtd Lions:40 CFR 122.41,40 CFR 122.61 and 15A NCAC 02H_0114
.....................................................................................................................
The certifications below mast be completed and sighs$by bg&the permit holder prior to the dranW(Pa mittreel and the
claw applies in the case of an ownership dhangc"quest. For a name change request,the signed Applicaat's Certification
is sufficient.
PE�tMI'f'1 EE CERTIF balder prior to ownasltfp dhaage):
1,Jared R. ich, this application for elownerslO change has been reviewed find is ac�auraDe mad complete
to the best my kxm 1 1 understand that if required parts of this alrplicatian am not mmpitted and the if dl
requw parting an 6 not uhciuded,this I iexion pottage will he t+t'<url,ed as inoam btdi~
--- to ' f9
\J Sigrcaatre Date
APPLICANT CERTIFICATION
1,Florcacia Gof iilex.d1w that this application for a namrlownership chsttge has been reviewed wd is accurate toad
comprete to the best of my knowk 19e. 1 umderstarhd that if all required parte of this application are real completed sad that
if all rquired a ppm formation is not included,this application package will be raeumied as incomplete.
/0 A Z//
OVA
PLEASE SEND THE COMPLETE APPLICATION PACKAGE TO.-
Division of Water Resourves
Water Quality Permitting Section
1617 Mail Service Centrr
Raleigh,North Carolina 27699-1617
NVD S PERMIT NAMPOVINEKS M CHANGF.REQUEST
PW 2 oft ArYftod 71Q117Ql4