NC0032361_Owner (Affiliation Change)_20220307

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„ NC DEPARTMENT OF ENVIRONMENTAL QUALITY
e� I , � DIVISION OF WATER RESOURCES
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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: [e-mail]
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
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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.
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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