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HomeMy WebLinkAboutNC0032361_Owner (Affiliation Change)_20220307 , -.w „ NC DEPARTMENT OF ENVIRONMENTAL QUALITY e� I , � DIVISION OF WATER RESOURCES \ii4e j �, 4,k-,�,,N WATER QUALITY PERMUTING SECTION NORTH CAROLINA NPDES PERMITTING Environmental Quality PERMIT NAME/OWNERSHIP CHANGE FORM I. CURRENT PERMIT INFORMATION: Permit Number: NCO()32361 or NCGS_/_ / / /_ 1. Facility Name: Balsam Center for Hope and Recovery RECEIVED II. NEW OWNER/NAME INFORMATION: MAR 072022 1. This request for a name change is a result of: a. Change in ownership of property/company NCDEQ/DWR/NppES b. Name change only _X_c. Other(please explain): Contact information update 2. New owner's name (name to be put on permit): Evergreen Foundation 3. New owner's or signing official's name and title: Denise Coleman (Person legally responsible for permit) Executive Diretor (Title) 4. Mailing address: 28A Oak St. City: Waynesville State: NC Zip Code: 28786 Phone: (828) 421-7483 (cell) E-mail address: dcoleman@evergreennc.org III. FACILITY AND DISCHARGE INFORMATION 1. Will the waste stream for the facilityremain the same as under the previous owner? Yes No 0 2. Will the treatment system and discharge location remain the same? Yes Er No 0 "No Responses" If either or both of these questions are answered"No"then more information will be needed to review the request. Please attach documentation to describe and explain the changes to the facility activities, waste stream, treatment process or outfall location. The Division may not be able to process the Permit Name/Ownership Change request and may require that the new owner file a new permit application. --', North Carolina Department of Environmental Quality I Division of Water Quality 512 North Salisbury Street 11617 Mail Service Center I Raleigh,North Carolina 27699-1617 o:wn-.,nao tin rtmax of En."a""'"vl a,rm 919.707.9000 • .-4 NPDES Name and Ownership Change Page 2 of 2 stream, treatment process or outfall location. The Division may not be able to process the Permit Name/Ownership Change request and may require that the new owner file a new permit application. 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 2. Legal documentation of the transfer of ownership (such as a property deed, articles of incorporation, or sales agreement) 3. Information to document facility,waste stream,treatment system or outfall changes as noted in item III above (if appropriate) Applicant's Certification: I, Denise Coleman , 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. I understand that Permit Name/Ownership Change can only take place through action taken by the Division of Water Resources and that no actions on my part or the part of my company result in the automatic transfer of permit coverage. i Signature: M U (`/` ({,3 V ....„ Date: 1/3/2022 THE COMPLETED 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 07 2021