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HomeMy WebLinkAboutNC0086169_Owner (Affiliation Change)_20210121 ROY COOPER Governor r: °~ MICHAEL S. REGAN 4"'°• 'rt _ 8,:erelan' 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