NCG550381_Owner (Name Change)_20211028

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ROY COOPER � ��' 3Governor ";y:5'
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ELIZABETH S.BISER a2c
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Secretary .,, —
S.DANIEL SMITH NORTH CAROLINA
Director Environmental Quality
PERMIT NAME/OWNERSHIP CHANGE FORM
I. CURRENT PERMIT INFORMATION:
Permit Number: NCH / / / / or NCG5 is /„3/q/ 1
1. Facility Name: g �,dl�Gf/
II. NEW OWNER/NAME INFORMATION: RECEIVE®
1. Th. request for a name change is a result of: Q C r 2 8 202'
s� a. Change in ownershipofproperty/company
g NCDEQ/DwR/NPDES
b. Name change only
c. Other(please explain):
2. New owner's name(name to be put on permit):
A erW1-621 V, 4 taIh/ E, 6agebnadri
3. New owner's or signing official's name and title:-A attikild. 069th/42 'Z
(Person ally responsible,or /�.permit)
(Title)
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4. Mailing address: /.3 idaleA, V �g, �q(y;City: Clyde,
State: /(G Zip Code: 57 , 1 Phone: ( ie/Z ) a jo.,g'i6
E-mail address: g dcq©od/ !� 7M&//, e yn
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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.
REQUIRED ITEMS:
1. This competed application form; _-
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[see reverse side of this page for signature requirements]
®E-' Asheville North CarolinaRegional DepartOfficement12090 of EnvironU.S. mentalHighway Q70ualitySwannanoa I Division of WNorthaterCarolina Resources
, 28778
NORTH CAROLINA
Department of Environmental Duality 828.296.4500

Page 2 of 2
Applicant's Certification:
I, �432- [ Q- ;� E Qt?pdj7jail , attest that this application for a
name/owney hip change has ben 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 and attachments are not included, this application package will be returned as
incomplete.
Signature: % Date: /0 a`trl >Z1
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G
THE CO PLE ED 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 11/2020