SW6100804_Change of Permittee Information_20220611

ULMLK U5L UNLY
Date Received Fee Paid Permit Number
There is NO FEE for updating project name or permittee information.
This form is to only to be used by the current permittee to notify the Division of.-
1) changes to the Point of Contact (signing official) for the current permittee (LLC, Corporation, HOA or POA);
2) changes to the mailing address, phone number or email address of the current permittee;
3) changes to the name of the project; and
4) changes to the legal corporate name as documented by a Name Change or Merger filed with the NCSOS.
A. NEW PERMIT INFORMATION
State Stormwater Permit Number: SW6100804
Are you updating
(check all that apply). -
If so, please provide the updated information:
Project name
❑ Corporation Name'
® Permit Contact Name2,3
Martin D Koon
® Permit Contact Title
Manager/Member
❑ Mailing Address3
❑ Phone number
❑ Email address
Provide documentation such as a Name Change / Merger filed with the NCSOS.
Provide supporting documentation such as NCSOS filing. The permit contact's position must be in accordance
with 15A NCAC 02H .1040 11.
If more than one point of contact or mailing address is being changed, please attach a separate sheet.
I, Martin D Koon , the current permittee, hereby notify DEMLR that I am making the
changes as listed in Sectio A above. I further attest that this application for an update to the permit information currently
on file is accurate om e es �y knowledge.
Signature: Date: y` ZZ-- 20 ZZ
I, , �� (�,I�/�i` lJ t c�h �✓ a Notary Public for the State of WodA
County of Y V j I Ke S do hereby certify that Ct r'-HN —b ko 6n
persq �hlyyr0i prpred before me this the day of r-[ l 20vA, and acknowledge the due
e\xmr3oiS oing instrument. Witness my hand and official seal,
r4tNt%R)JbIiCy�'� Z
County
My Comm. Exp.
rSign
2026
atur�P.� <
�, ;--
My coN4MilIJgW�expires
Stormwater Permit information Update Form Page 1 of 1 "ay 11, 2017