SW3170802_Application Form (Permit Information Update)_20211201

This form is to only to be used by the current permittee to notify the Division of-
1) changes to the Point of Contact (signing official) for the current permittee (LLC, Corporation, HOA or POA);
2) changes to the mailing address, phone number or email address of the current permittee;
3) changes to the name of the project; and
4) changes to the legal corporate name as documented by a Name Change or Merger filed with the NCSOS.
State Stormwater Permit Number: SW3170802
B. CERTIFICATION OF PERMITTEE
1, -1 - 64r-' 4 0 Pet — , the current permittee, hereby notify DEMLR that I am making the changes as listed
in Section A above. I further attest that this application for an update to the permit information currently on file is accurate
and complete.to the besoAmv knowledge,
Is
Date,
a Notary Public for the State of
County of t4v / 0 do hereby certify that A �7-��
personally appeared before me this the 7" day of 20(D/ , and acknowledge the due
execution of the forgoing instrument, Witness my hand and official seal,
My commission expires OC�,,i- -�-2
Stormwater Permit Information Update Form Page 1 of 1 May 11, 2017