NC0036935_Owner (Affiliation Change)_20200714

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Water Resources
ENVIRONMENTAL QUALITY
PERMIT NAME/OWNERSHIP CHANGE FORM
CURRENT PERMIT INFORMATION:
Permit Number: NC0036935
1. Facility Name: Pine Mountain Lakes WWTP
II. NEW OWNER/NAME INFORMATION:
ROY COOPER
MICHAEL S. REGAN
LINDA CULPEPPER
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1. This request for a name change is a result of:
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_a. Change in ownership of property/company
JUL 15 2020
_b. Name change only
DWR SECTION
_X_c. Other (please explain): New Responsible Official INFORMATION PROCESSING UNIT
2. New owner's name (name to be put on permit):
3. New owner's or signing official's name and title: Edith Stitt
(Person legally responsible for permit)
(Title)
4. Mailing address: 2885 Pine Mountain Drive City: Connelly Springs
State: NC Zip Code: 28612 Phone: [phone]) (828-390-9131)
E-mail address: pinemountainooa(@gmail.com [e-mail]
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/div isiotus/water-resources/water-resources-pemiiWwastewater-brmch/npdes-wastewater-permits

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NPDES Name & ownership Change
Page 3 of 3
Applicant's Certification:
1, Edith Still, 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: A �4�t-_ Date: �� It
� � 20 Z.a
THE COMPLETED APPLICATION PACKAGE, INCLUDING ALL SUPPORTING
INFORMATION & MATERIALS, SHOULD BE SENT TO THE FOLLOWING ADDDRESS:
NC DEQ / DWR / NPDES
1617 Mall Service Center
Raleigh, North Carolina 27699-1617
Version 1112017