NC0003794_Owner_20201211

DocuSigni Envelope ID: 2A40548D-7EOD-4695-8787-5844C4D1 DDDO
Water Resources
ENVIRONMENTAL QUALITY
RECEIVED
DEC 11 2020
NCDEQ/DWR/NPDES
PERMIT NAME/OWNERSHIP CHANGE FORM
ROY COOPER
t;ovcnlor
MICHAEL S. REGAN
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DANNY SMITH
I. CURRENT PERMIT INFORMATION:
Permit Number: NC00 0 / 3 / 7 / 9 / 4 or NCG5 / / / /
1. Facility Name: Wilmington Processing Plant
II. NEW OWNER/NAME INFORMATION:
1. This request for a name change is a result of:
a. Change in ownership of property/company
_X_b. Name change only
c. Other (please explain):
2. New owner's name (name to be put on permit):
Wilmington Fiber Optic Facility
Director
3. New owner's or signing official's name and title: William R. Lopatka
(Person legally responsible for permit)
Plant Manager
(Title)
4. Mailing address: 310 North College Road City: Wilmington
State: NC_ Zip Code: 28405 Phone: [phone]
E-mail address: lopatkawrc. corning.com
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 l Environmental Quality Water Resources
1617 Mail Service Center i Raleigh, NC 27699-1617
919 807 6300 919-807-6389 FAX
https://deg. nc. gov/about/d i v i lions/water-resources/water-resources-perm its/wastewater-branch/npdes-wastewater-perm its

DocuSign Envelope ID: 2A40548D-7EOD-4695-8787-5844C4D1 DDDO
NPDES Name & Ownership Change
Page 2 of 2
Applicant's Certification:
William R. Lopatka , 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: cl�/ (AL " U2 "297 Date: December 1, 2020
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 7/2016