NCG551079_Owner (Affiliation Change)_20200203

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- MICHAEL S. REGAN
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LINDA CULPEPPER
Miter er st:f.'sourc s Director
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NPDES Certificate of Coverage (CoC)
NCG550000 OWNERSHIP CHANGE FORM
I. Please enter the CoC number for which the change is requested.
Certificate of Coverage
N C G 5, 5 1 0 7 9
II. Please provide the following for the requested change (revised permit).
a. Request for change is a result of: ® Change in ownership of the residence/property
❑ Name change of the facility or owner
If other please explain:
b. Permit will be issued to (company � 1'
name, if applicable): V�� - DA, a fa-LA
c. Person legally responsible for permit: MO RS VA- ki.31 KZU)-1
RECEIVED First ILMJ I �} Last
Title
FEB 0 3 2020 5'Zi '1k0Oi iVl(tn.7
Permit Holder Mailing Address
NCDEQIDWR/NPDES 31
City State Zip
( \�) 5-b(04A-
Phone E-mail Address
d. Facility name(discharge): 169 Black Angus Rd SFR
e. Facility address: 169 Black Angus Rd
Address
Leasburg NC 27291
„City State Zip
f. Facility contact person: W.)v l.0 A1/1" 1i.
[if different from Owner] i-6
First MI Last
ectv7k) 4-5S ✓ G 6 -
Phone E-mail Address
III. Permit contact information(if different from the person legally responsible for the permit)
Permit contact:
First MI Last
Title
Mailing Address
City State Zip
( )
Phone E-mail Address
Will this permitted facility continue to discharge the same volume and type of wastewater as
prior to this ownership or name change?
® Yes
❑ No (please explain)
Rc„iec,i 110(117

NCG550000 OWNERSHIP CHANGE FORM,
Page 2 of 2
VI. Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS
ARE INCOMPLETE OR MISSING:
® This completed application is required for both name change and/or ownership change
requests.
® Legal-documentation of the transfer of ownership(such as a property deed,relevant pages of a
contract, or a bill of sale) is required for an ownership change request.
The certifications below must be completed and signed by the new applicant in the case of an ownership
change request.
APPLICANT CERTIFICAT ON
VJ I, 1YI \k I.t1,1Qttest 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 is not included,this application
package will be returned as incomplete.
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Si attireDate
PLEASE SEND THE COMPLETE APPLICATION PACKAGE TO:
NC DEQ/DWR/NPDES
1617 Mail Service Center
Raleigh,NC 27699-1617
Revised 11/2017 •