NCG551049_Owner (Name Change)_20210203

£ ROY COOPER
MICHAEL S. REGAN
LINDA CULPEPPER
Water Resources rn., .:•:r;,,fr
ENVIRONF`ENTA,.QUALM"
NPDES Certificate of Coverage (CoC)
NCG550000 OWNERSHIP CHANGE FORM
I. Please enter the CoC number for which the change is requested.
Certificate of Coverage
N C G 5 5 to ci V
II. Please provide the following for the requested change(revised permit).
a. Request for change is a result of: [ Change in ownership of the residence/property
Name change of the facility or owner
If other please explain:
b. Permit will be issued co (company
name,if applicable): into Se, L L C
c. Person legally responsible for permit: C Fipples \-V fluse
First MI Last
Pl e. be r
RECEIVED Title
PO QDx I
FEB 0 3 2021 Permit Holder Mailing Address
Clyde agial
NCDEQ/DWR/NPDES City State Zip
(SAS ) 77S—76�0
Phone E-mail Address
d. Facility name(discharge): G S c *ey I4ouhftc r €x press'Jay .5 0y-0.9e.
e. Facility address: PPd4ilar's s uevx.
S Address
Wa.yne.CVNei AI 8186
City State Zip
f. Facility contact person: Met i SSG ('1 s I rreC
[if different from Owner] First MI Last
(? j047rn )1,e(€icL1-1', n•e$'
Phone E-mail Address
III. Permit contact information(if different from the person legally responsible for the permit)
Permit contact:
First MI Last
Title
Mailing Address
City State Zip
( )
Phone E-mail Address
N Will this permitted facility continue to discharge the same volume and type of wastewater as
pri r to this ownership or name change?
[ Yes
❑ No (please explain)
Revised 11/2017

NCG550000 OWNERSHIP CHANGE FORM
Page 2 of 2
VI. Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS
liINCOMPLETE OR MISSING:
his completed application is required for both name change and/or ownership change
requests.
Legal documentation of the transfer of ownership(such as a property deed,relevant pages of a
contract, or a bill of sale) is required for an ownership change request.
The certifications below must be completed and signed by the new applicant in the case of an ownership
change request.
APPLICANT CERTIFICATION
I, , 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 is not included, this application package will be
returned as incomplete.
a,,,Lw- t / - zi- 2.l
Signature Date
PLEASE SEND THE COMPLETE APPLICATION PACKAGE TO:
NC DEQ/DWR/NPDES
1617 Mail Service Center
Raleigh,NC 27699-1617
Revised 11/2017 .