NCG550429_Owner (Affiliation Change)_20220114

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ROY COOPER ', _ '
Governor ii - RECEIVED
ELIZABETH S.BISER f a`
Secretory `-'° °' " JAN 14 2022
S.DANIEL SMITH NORTH CAROLINA
Director Environmental Quality
NCDEQ/DWRINPDES
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 C Lfl 9
II. Please provide the following for the requested change(revised CoC).
a. Request for change is a result of: 0 Change in ownership of the residence/property
0 Name change of the facility or owner
If other please explain:
b. CoC will be issued to(person's name
or company name,if applicable):
c. Owner: person legally responsible for �^
CoC: exzvslHL Lvvvr,' )ftiv JL'f},‘1
First MI Last
OWNl=i2
Title
7o be X (a?I (v
Permit Holder Mailing Address
ASP- rVTt L. E /l)< ZOO 1 (1)
��jj Q 1City J 7 State Zip
(S -& ) ?- -(p 5 o i r,- (�4I'IIn i'i cAilj✓IGI.'1 Q,911AII.�dr11
Phone E-ntl Addi'ess �J
d. Facility name(if applicable):
e. Facility address: I o VI e‘-het- La Ilk
Address
City State Zip
1 f. Facility contact person:
[if different from Owner] First MI Last
( )
Phone E-mail Address
III. Contact person (if different from the person legally responsible for the CoC)
First MI Last
Title
Mailing Address
City State Zip
( )
Phone E-mail Address
No Carolina m of oil Quality I Division Water Rerces J/ 512 North rth SalisburyaroliDep art Streetent 11617Envir Mail Serviceental Center I Raleigh.North
of Carolinasou 27699-1617
«mm"oi e�.6ommw wanr �" 919.707.9000

Type: CONSOLIDATED REAL PROPERTY
Recorded: 10/28/2021 2:16:59 PM
Fee Amt: $64.00 Page 1 of 5
Buncombe County, NC
Drew Reisinger Register of Deeds
BK 6140 PG 723 - 727
SATISFACTION: The debt evidenced by this Note has been
satisfied in full this the_day of ,20 .
Signed:
Recording:Time,Book and Page
Parcel Identifier No. 9618-99-3704.00000
Mail after recording to:Reed Law Firm,P.C.,168-B South Liberty Street,Asheville,North Carolina 28801
Mail after recording to: Reed Law Firm,P.C.,168-B South Liberty Street,Asheville,North Carolina 28801 (Box#23)
This instrument prepared by Reed Law Firm,P.C.,168-B South Liberty Street,Asheville,North Carolina 28801
10 Riester Lane
Brief Description for the index M&B DB 3406,Pg.675
NORTH CAROLINA DEED OF TRUST
Purchase Money-First Lien Position
THIS DEED of TRUST made 28t"day of October,2021,by and between:
GRANTOR TRUSTEE BENEFICIARY
•
Crystal Lynn San Juan and spouse, REED LAW FIRM,P.C. Carol Harris,unmarried
David Philip San Juan
168-B South Liberty Street P.O.Box 16279
P.O.Box 6316 Asheville,North Carolina 28801 Asheville,NC 28816
Asheville,NC 28816
Enter in appropriate block for each party:name address,and,if appropriate,character of entity,e.g.corporation or partnership
The designation Grantor,Trustee,and Beneficiary as used herein shall include said parties,their heirs,successors,and assigns,and
shall include singular,plural,masculine,feminine or neuter as required by context.
WITNESSETI-I,That whereas the Grantor is indebted to the Beneficiary in the principal sum of EIGHTY THREE THOUSAND AND
No/100s DOLLARS($83,000.00), as evidenced by a Promissory Note dated October 28, 2021, the terms of which are incorporated
herein by reference.
The final due date for payments of said Promissory Note,if not sooner paid,is October 28,2028.
9ubntitted electronically by Reed Law Firm.PC in cotnnllance with North Carolina statutes_eovernine recordable documents and
the terms of the submitter agreement with the Buncombe County Register of Deeds.
Book: 6140 Page: 723 Page 1 of 5

NCG550000 OWNERSHIP CHANGE FORM
Page 2 of 2
Will this permitted facility continue to discharge the same volume and type of wastewater as
prior to this ownership or name change?
.02 Yes
❑ No(please explain)
V. Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS
;E INCOMPLETE OR MISSING:
This completed application is required for both facility-name change and/or facility ownership
change requests.
leLegal 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, a',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
/`Z, Za 2z
Si ature Date
PLEASE SEND THE COMPLETE APPLICATION PACKAGE TO:
Mr. Charles H.Weaver
NC DEQ/DWR/NPDES
1617 Mail Service Center
Raleigh,NC 27699-1617
[e-mail]