NCG530130_Owner (Name Change)_20210216

ROY COOPER41 MICHAEL S.REGAN
lriciR\~ S.S.DANIEL SMITH
NORTH CAROLINA
Environmental Quality
PERMIT NAME/OWNERSHIP CHANGE FORM
CURRENT PERMIT INFORMATION:
Permit Number: NCOO / / / / or NCG53 /®/O/O/0
--- NCB 5`501v0
1. FacilityName:
H. NEW OWNER/NAME INFORMATION:
1. This request for a name change is a result of:
'V a. Change in ownership of property/company
ECEIVED
FEB 6 ZOZ1
b. Name change only Z
NCDEQ/DWR/NPDES
c. Other(please explain):
2.New owner's name(name to be put on permit):
3. New owner's or signing official's name and title:
r-e �<' �'c�nvi 1 y Pro 't .C—
(Person legally responsible for permit)
D,,.„
freAecic � (Title)
Oc,OrJe�S
4. Mailing address: City:
State: Zip Code: Phone:
9(4(A) ioct 2?9 o(f 4-1-0((- 3 o
E-mail address: f^2 _ 2 —3
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THIS APPLICATION PACKAGE WILL NOT BE ACCEPTED BY THE DIVISION UNLESS ALL OF
THE APPLICABLE ITEMS LISTED BELOW ARE INCLUDED WITH THE SUBMITTAL.

C ec-h` `c.at-c e . i a co-? )Ce,71 c,v ()
Applicant's Certificatioth/
clejer,-c t /t",eiw b'e'
I, e �j� !,e�a 1 c ,attest that this application for a
nameownerss' ip changellas been reviewe�an3 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.
Si tore: Date: 9I
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
North Carolina Department of Envinamiental Quality Division of Water Resources
1617 Mail Service Center I Raleigh_Noah Carolina 27699-1617
919-70:-9000

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