NC0001643_Owner (Affiliation Change)_20200709

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ROY COOPER `/5 l , 2
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Governor �M�_ a= RECE
MICHAEL S.REGAN ,� nA . '�ED
Secretary leweno o„
LINDA CULPEPPER NORTH CAROLINA jilt14 1010
Director Environmental Quality
NCDEQ/DWR/Np pcn
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PERMIT NAME/OWNERSHIP CHANGE FORM
I. CURRENT PERMIT INFORMATION:
Permit Number: NCO() 6/Li to/1/ 3or NCG5 / / / /
1. Facility Name: Eder "Reck\ a5taIIkt 1n1 lArrit
II. NEW OWNER/NAME INFORMATION:
1. This request for a name change is a result of:
1� Change in ownership of property/company
b. Name change only
c. Other(please explain):
2. New owner's namem (name to be put on permit):
c.41 ©f C.�er-1 l%det.1 1 N� a7agg
3. New owner's or signing official's name and title: r d›,-4L
(Person legall responsible for permit)
T�kcftry, CI c , J eer
(Title) VV
4. Mailing address:?.O. BOX 70 City: l denl
State: L Zip Code: a` I5 Phone: (336) c 23 — 2110
E-mail address: -4 5 e l-Li a ed e lJ N� . US
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]
DE ) North Carolina Department of Environmental Quality I Division of Water Resources
// S12 North Salisbury Street 11617 Mail Service Center I Raleigh,North Carolina 27699 1617
DWIrlesst NORTH CP.ROUNA
th,* /d 919.707.9000

Applicant's Certification:
I, cry A. Ne-1t�� x�"Lit .. C, y f(aNa�erattest 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: AI a 1,La._. Date: 7 9 aO
g � /
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

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