NCG551633_Owner (Name Change)_20220118

ROY COOPER `='{ ` ` y
GovernorAJ,��,�Ss%�' 1 r
ELIZABETH S.BEER ` a
Secretary
S.DANIEL SMITH NORTH CAROLINA
Director Environmental Quality
fit-: - - - - - - - -- -
- ES Cea ca>te.of Colierage C'®C)
I. Please enter the CoC number for which the change is requested.
Certificate of Coverage
14 C G 5 5 / (O 3 3
II. Please provide the following for the requested change(revised CoC).
a. Request for change is a result of: Change in ownership of the residence/property
❑ 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): • ,150�, S .
c. Owner:person legally responsible for C
CoC: t\U SoY\ J �DvL)1Z-,S
RECEIVED First MI ,mot
JAN 18 2022 Title
Va\yyvdc ` Inc
NCDEQIDWRINPDtS Permit Holder Mailing Address
City State Zip
( 919) 3s)•3(05S o�.�,n. 3.\Ouut.s,es P .-CbT
Phone E-mail Address
d. Facility name(if applicable):
e. Facility address: 50.. i&S2_ oLD
Address
City State Zip
f. Facility contact person:
[if different from Owner] First MII 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
.
North Carolina Department of Environmental Quality I Division of Water Resources
512 North Salisbury Street 11(17 Mail Service Center I Raleigh,North Carolina 27699-1617
ara•+ 1u+'rri rulltal oadr 919.07,9000

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?
P Yes
❑ No(please explain)
V. Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS
ARE INCOMPLETE OR MISSING:
This completed application is required for both facility-name change and/or facility ownership
change requests.
FP
Legal 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.
APPL ANT CERTIFICATION
I, 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 incom lete.
ai / /a \
attire 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]

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TO HAVE AND TO HOLD the aforesaid lot or parcel of hand and all prig ileges and appurtenances thereto belonging to the Grantee in
fee simple.
And the Grantor covenants with the Grantee.that Gnuuur is sei'ed of the premises in fee simple.has the right to convey the same in fee
simple,that title is marketable and free and clear of all encumbrances.anti that Grantor will warrant and defend the title against the lawful
claims of all persons whomsoever.other than the following exceptions:
•
1. Ad valorem taxes for the current year and subsequent years.
2. Easements.restrictions and other matters of record affecting title to the subject property.
IN WITNESS WHEREOF,the Grantor has duly executed the foregoing :of the(I2 ati y IV:t above written.
'0. 0. (SiGAL)
(Entity Name) enneth'I odd Howes
By: MEAL"(
Print/Type Name & Title:
By:
(_SEAL.Z
PrintlType Name & Title:
State..f IQC -Comity or City of b^w
I. the undersigned Notary Public of tine County or City of r'` and State
aforesaid. certify that K meth Todd Homo. personally appeared before me this day and
acknowledged the due c‘ecution of the foregoing instru tint for the purposes therein expressed.
Witness my hand and Notarial stamp or seal this day of Cttt e
'pip
J Nolan'
ivly Commission Expires: i1x"t/2aIL ---
(Affix Notary Seal) 1 ( Notary's Printed or Type Alas c
THOMAS JOHN KREGER
NOTARY PUBLIC
Durham County
North Carolina
My Commission Expires Jan.27,2021