NC0025445_Owner (Affiliation Change)_20201111

ROY COOPER
�:- MICHAEL S. REGAN
i`1 LINDA CULPEPPER
NORTH CAROLINA
Environmental Quality
PERMIT NAME/OWNERSHIP CHANGE FORM
CURRENT PERMIT INFORMATION:
Permit Number: NCOO 2 / 5 / 4 / 4 / 5 or NCG5 / / / /
1. Facility Name: City of Randleman Wastewater Treatment Plant
II. NEW OWNER/NAME INFORMATION:
1. This request for a name change is a result of:
a. Change in ownership of property/company RECEIVED
b. Name change only NOV 11 2020
_Jc. Other(please explain): Change in Responsible Official Only.
NCDEQ/DWRINPDES
2. New owner's name(name to be put on permit):
L1 ; I1 ,; hnSon
3. New owner's or signing official's name and title:
(Person le responsible for permit)
C` M e —
(Titl
.03
4. Mailing address: 204 South Main Street City: Randleman
State:NC Zip Code: 27317 Phone: [phone]
E-mail address: Uy n S0 n 64- C, c Vzinch ion. - coin
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]
-1711\9S3
North Carolina Department of Environmental Quality I Division of Water Resources
1617 Mail Service Center I Raleigh,North Carolina 27699-1617
919-707-9000

NPDES Name&Ownership Change
Page 2 of 2
Applicant's Certification:
I, U ► 1 .. evil L rf Sof. ,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: L,JLJJP Date: II / /020
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
Version 4/2019