HomeMy WebLinkAboutNC0086169_Owner (Affiliation Change)_20210121 ROY COOPER
Governor
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°~ MICHAEL S. REGAN
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LINDA CULPEPPER
Water Resources Interim D,reclar
ENVIRONMENTAL QUALITY
PERMIT NAME/OWNERSHIP CHANGE FORM
I. CURRENT PERMIT INFORMATION:
Permit Number: NC00_8 / 6 / I / 6 / 9
1. Facility Name: Fiber Optic Facility
II. NEW OWNER/NAME INFORMATION: RECEIVED
1. This request fora name change is a result of:
a. Change in ownership of property/company JAN 2 1 2021
b. Name change only NCDEQIDWRINPDES
X_c. Other(please explain): Change in Responsible Official Only
2. New owners name(name to be put on permit):
•3. New owner's or signing official's name and title: Terri A.Williams
(Person legally responsible for permit)
Plant Manager •
(Title)
4. Mailing address: 14556 Hwy 601 S City: Midland
State: NC Zip Code: 28107 Phone: (704) 569- 6 04/
E-mail address: WilliamsTA2@coming.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 I Environmental Quality I Water Resources
1617 Mail Service Center I Raleigh,NC 27699-1617
919 807 6300 919-807-6389 FAX
https://deg.nc.gov/about/divisions/water-resources/water-resources-permits/wastewater-branch/npdes-wastewater-permits
NPDES Name&Ownership Change
Page 2 of 2
Applicant's Certification:
I, Terri A. Williams , attest that this application for a name/ownership change has been
reviewed and is accurate and complete to the best of my knowledge. l 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: -�-e.ut 1-A) Date: /5Ii
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 11/2017