NC0071463_Owner (Affiliation Change)_20220414

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ROY COOPER
Governor ,
ELIZABETH S.BISER
Secretary P 4VtiO
S.DANIEL SMITH NORTH CAROLINA
Director Environmental Quality
PERMIT NAME/OWNERSHIP CHANGE FORM
I. CURRENT PERMIT INFORMATION:
Permit Number: NCO() 7 / 1 / 4 / 6 / 3 or NCG5 / / / /
1. Facility Name:Cei71T� -Pc.Ark er1111(1c\ CORK L(-C
II. NEW OWNER/NAME INFORMATION:
1. This request for a name change is a result of:
a. Change in ownership of property/company
b. Name change only
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c. Other(please explain): CA
2. New owner's name (name to be put on permit):
U/ A
3. New owner's or signing official's name and title: gt I` ve
(Person legally responsible for permit)
c5r. I I \ Opzr •
(Title)
4. Mailing address:gr2Sc. for.cLift., e lok c`.2, LtW City: (�' t., (&
State: ISO Zip Code: (6>3l 0(5 Phone: ( 3 0-1 ) - 9 ('0Li
E-mail address: 6Ir4Ir1Saw JJQc r. ���✓l`� Pc r'1 vice r CAI
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)
[see reverse side of this page for signature requirements]
North Carolina Department of Environmental Quality I Division of Water Resources
512 North Salisbury Street 1 1617 Mail Service Center I Raleigh,North Carolina 27699-1617
NORM CAROLINA
Department of Environmental Qualify 919.707.9000

NPDES Name&Ownership Change
Page 2 of 2
Applicant's Certificatio :
I, $)t_ (_ 71/S011 , 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 i complete.
Signature: ��� Date: /1 2—a"
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, NC 27699-1617
Version 7/2016