NCG100079_Owner Affiliation Change (2)_20210623

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
5) Reason for this change.
A result of:
If other please explain:
Form cif no Facility Name/Ownership Change)
Debbie G. Lassiter/Owner/Ma nag er
Title
2646 NC Hwy 222 E.
Mailing Address
Fremont NC 278ou
city State zip
(919 242-6154 Partsgir1s@embarqmafl,com
Telephone E-mail Address
919 1242-7172
Fax Number
❑ Employee or management change
13 Inappropriate or incorrect designation before
Q Other
I
Herbert H. Green passed away Dec 10, 2020
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The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
I� Debbie G. Lassiter ,attest that this application for this change in Owner Affiliation
ns (person legally respoible for the permit) has been reviewed and is accurate and complete to the best of my
knowledge. I understand that if all required parts of this form are not completed, this change may not be
processed-6
6-23-w2021
Signature
Date
PLEASE SEND THE COMPLETED FORM TO:
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
L
For more information or staff contacts, please call [phone] or visit the websrte
at: http://deq.nc.goU/aboutldivisions/energy-mineral-land-resources/stormwater
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