NC0055905_Owner (Name Change)_20220228

lir
���.� ROY COOPER
Y .,r.� -c,"„ (iuverrnr
4.4711°,� , MICHAEL S. REGAN
� 1 i n ,,,,,v,aty
),„„,„„
S. DANIEL SMITH
4s :, 0.1=0.e'_I
NORTH CAROLINA
Environmental Quail:),
PERMIT NAME/OWNERSHIP CHANGE FORM
I. CURRENT PERMIT INFORMATION:
Permit Number: NC00 5/5/9/0/5 or NCG5 / / / /
1. Facility Name: Waterford Place, Brevard,NC
e
II. NEW OWNER/NAME INFORMATION:
1. This request for a name change is a result of ®ECE
a. Change in ownership of property/company �( _ r
FEB B 2 8 2022
x b. Name change only
c. Other(please explain): NCDEQ/D FuNPD!s
2. New owner's name(name to be put on permit):
Ann Bruffy,
3. New owner's or signing official's name and title: Ann Bruffy
(Person legally responsible for permit)
President, Waterford Place Property Owners Association
(Title)
4. Mailing address: 10 Lakeview Court City: Brevard
State:NC_ Zip Code: 28712. Phone: [phone]
E-mail address: [e-mail]
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 completed application form
410 egal documentation of the transfer of ownership (such as a property deed, articles of incorporation,
or sales agreement)
e 'a*ate Via
te
E
North Carolina Department of Environmental Quality I Division of Water Resources
1617 Mail Service Center I Raleigh,North Carolina 27699-1617
919-707-9000

NPDES Name&Ownership Change
Page 2 of 2
[see reverse side of this page for signature requirements]
Applicant's Certification:
I, Ann Bruffy , 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 and attachments are not included, this application package will be returned as
incomplete.
ee
2 /22
Signature: Date: /9
goTTHE COMPLETED APPLICATION P• C CLUDING 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