NCG080720_Ownership Change_20180928 (2)

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ROY COOPER
Mar e Mx
MICHAEL S. REGAN
Secretary
LINDA CULPEPPER NORTH CAROLINA
Enrf
Interim DireDireEnvironmental Quality
ctor
PERMIT - NAME/OWNERSHIP CHANGE FORM
I. CURRENT PERMIT INFORMATION:
Permit Number:NCS/0/7 /2 /0 or NCG5 / / /
1. Facility Name: Wilkinson Shop
II. NEW OWNER/NAME INFORMATION:
1. This request for a name change is a result of:
X 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):
Blythe Construction,Inc.
3. New owner's or signing official's name and title: P. Fredrick O'Dea Jr.
(Person legally responsible for permit)
VP.CFO.Treasurer and Secretary
(Title)
4. Mailing address: 2911 N Graham St City: Charlotte
State: NC Zip Code: 28206 Phone: ( 704 ) 375-8474
E-mail address: [e-mail]
THIS APPLICATION PACKAGE WILL NOT BE ACCEPTED BY THE DIVISION UNLESS ALL OF
THE APPLICABLE ITEMS LISTED ON PAGE 2 ARE INCLUDED WITH THE SUBMITTAL.
1iPage ,

1.
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)
Applicant's Certification:
I, P. Fredrick O'Dea Jr. , 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: it 7 'ieG(a. Date: 9/Z1'//t'
THE COMPLETED APPLICATION PACKAGE, INCLUDING ALL SUPPORTING
INFORMATION & MATERIALS, SHOULD BE SENT TO THE FOLLOWING ADDDRESS:
NC DEQ / DWR / NPDES
Attention: Ms. Wren Thedford
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
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