NC0070033_Owner (Name Change)_20220621

ROY COOPER
Governor
MICHAEL S. REGAN
Secretary
LINDA CULPEPPER
Water Resources Interim Director
ENVIRONMENTAL QUALITY
PERMIT NAME/OWNERSHIP CHANGE FORM
I. CURRENT PERMIT INFORMATION:
Permit Number: NC001 / Q / 0/ 3 /3 or NCG5P/Wk.
/ / / /
1. Facility Name: al'A-Nc�(2.v,J Keei ct_,S 1�Q!�
RECEIVED
II. NEW OWNER/NAME INFORMATION:
JUN 212022
1. This request for a name change is a result of:
a. Change in ownership of property/company NCDEQ/DWR/NPDES
b. Name change only
c. Other(please explain):
2. New owner's name(name to be put on permit):
U-A-Atj—t,i.) PIOPae—as LLC.
3. New owner's or signing official's name and title: U tk?' l R-k
(Person legally'responsible for permit)
1 (Title)
4. Mailing address: GA- I C V` C9�5 City: �.,0-4 6-re 1"
State: V(t Zip Code: al l Phone: ( )
E-mail address: 1f`-6 i e t-0 4 .s
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]
State of North Carolina I Environmental Quality I Water Resources
1617 Mail Service Center I Raleigh,NC 27699-1617
919 807 6300 919-807-6389 FAX
https://deq.nc.gov/about/divisions/water-resources/water-resources-permits/wastewater-branch/npdes-wastewater-permits

NPDES Name&Ownership Change
Page 2 of 2
Applicant's Certification:MA),
I, )4{A-v-1 JJ , attest that this application for a
name/ownership change ha 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.
Signature: Date: (0/19 1 ae),
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 11/2017

1113110110111111111111111111
2022013771
DAVIDSON CO,NC FEE$26.00
STATE OF NC REAL ESTATE EXTX
$4100.00
PRESENTED R.RECORDED:
06-16-2022 11:58:22 AM
MICHAEL HORNE
REGISTER Of DEEDS
DEPury
BY:NATASHA MCKENZIE
BK: DE 2552
PG: 1596-1598
Excise Tax$4,100.00
Drafted Tax PIN: 6821-02-68-0230
by: George D. Humphrey,Esq.
Return to: 206 West Center Street, Suite Property 1380 Quail Place Drive
A, Lexington,North Carolina Address: Winston-Salem,NC 27127
27292-3056
This instrument prepared by: George D. Humphrey, III, a licensed North Carolina attorney.
Delinquent taxes, if any, to be paid by the closing attorney to the county tax collector upon
disbursement of closing proceeds.
NORTH CAROLINA )
DAVIDSON COUNTY ) GENERAL WARRANTY DEED
THIS DEED made this d.$'4' day of June, 2022, by and between FROG LEVEL
INDUSTRIES, INC, a North Carolina corporation (hereinafter referred to as "Grantor") whose
mailing address is 3042 Panther Ridge Lane,Lewisville,NC 27023 and QUAIL RUN MHP PADS
LLC,a North Carolina limited liability company,whose mailing address is 206 West Center Street,
Suite A, Lexington, North Carolina 27292-3056, (hereinafter referred to as "Grantee"). The
designation Grantor and Grantee, as used herein, shall include said parties, their heirs, successors,
and assigns, and shall include singular, plural, masculine, feminine or neuter, as required by
context.
WITNESSETH:
THAT the Grantor, for a valuable consideration paid by the Grantee, the receipt of which
is hereby acknowledged, has and by these presents does grant, bargain, sell and convey unto the
Grantee in fee simple, all those certain lots or parcels of land situated in Davidson County,North
Carolina, and more particularly as follows:
SEE ATTACHED SHEET LABELED EXHIBIT A
INCORPORATED HEREIN BY REFERENCE
This property is not the primary residence of the Grantor

The property hereinabove described was acquired by Grantor by instrument recorded in
Book 2132, Page 290,Davidson County Registry.
TO HAVE AND TO HOLD the aforesaid lots or parcels of land and all privileges and
appurtenances thereto belonging to the Grantee in fee simple.
And the Grantor covenants with the Grantee, that Grantor is seized of the premises in fee
simple,has the right to convey the same in fee simple,that the title is marketable and free and clear
of all encumbrances, and that Grantor will warrant and defend the title against the lawful claims
of all persons whomsoever, except for the exceptions hereinafter stated. Title to the property
hereinabove described is subject to easements, rights of way and restrictions of record, if any, all
building, zoning, and environmental laws, codes, and ordinances, all.matters that would be
disclosed by an accurate survey and physical inspection of the property,and 2022 ad valorem taxes
and subsequent years.
IN WITNESS WHEREOF, the Grantor has executed this instrument on the day and year
first above written.
FROG LEVEL INDUSTRIES, INC.
By: //' er- (SEAL)
George .Humphrey, III,
Authorized Signatory
THER'ESA KAY WILLIAMS
Notary Public, North Carolina
Stbkes County
NORTH CAROLINA My_Commission Expires
COUNTY OF FORSYTH January 13,2024
I certify that the following person(s),either being personally known to me or proven by satisfactory
evidence, personally appeared before me this day, each acknowledging to me that he or she
voluntarily signed the foregoing document for the purpose stated therein and in the capacity
indicated: George D. Humphrey, III
Date: June 15 2022
(Printed name)
Notary Publ. -14 e t`t.5 r W i 1 I c 5
My Commission Expires: ) P /3 `a D a,1