NC0020061_Owner (Affiliation Change)_20220707

ROY COOPER
,\1l{'J1AJ'L S. RI IAN
tipler {'SflflFi"PS
F` Vlu{}U{ Lh IAl- 41JM1_-rF
PERMIT NAMEI WNER HIP CHANGE FORM
I. CURRENT PERMIT INFORMATION;
Permit plumber-- N C 00 0 i-0-i i (v I � or N GG5_1_i_!_i
1- Fac;kty Name: ' P f1 -z—
II. NEW OWNERlNAME INFORMATION;
1, This request For a name change is a result of:
a. Change in ownership of properiylcompany
b- Name change only
t. Other (please explain); �.
2- New owner's name (name to be put on permit):
3. New owner's or signing official's name and title;
(Person legally resporsible for permit)
i tt `� (Title)
4. Mailing address; [ ll J+.c{tt\t�.�C oty- 46 01 _
state-. Zip code:_2t Phone;
E-mail address: ��c�rol'4�C Qom• 1� --
THIS APPLICATION PACKAGE WILL NOT BE ACCEPTED BY THE DIVIE10N UNLESS ALL OF THE
APPLICABLE ITEMS LISTED BELOW ARE INCLUDED WITH THE SUBMITTAL,
REQUIRED ITEMS.
1- This completed application form
- Legal documentatlon of the transfer of e nefship (such as a property deed, articles of
inoofporation, or sales agreement)
[see reverse side of this page for signatt_Ire requirements)
Stale of Nonh Carolina l Ern-IfonmentaI Quality I Watcr Rimyurcvs
1617 Mail .SeAjcr C'ratcr i Raleigh- N-C ? 7699-1617
919 W 000 919•54'7-6399 FAX
IllLpy-Wideq, [s

Applicant's CertifIcatlon:
NPOES Nanl$ & Ck%- drO:ip Chdnye
Page 2 of 2
attest that this application for a
name/ownership change has been reviewed and is accurate and complete to the best of mar
knowledge. I understand that if all required parts of this application are not completed and that
if all reqLrirgd supporting information and attachments are not included. this application
package will be re€ui-ned as incomplete.
Signature: _ Date; 1- - S —o o o
THE COMPLETED APPLICATION PACKAGE, INCLUDING ALL SUPPORTING
INFORMATION & MATERIAL , SH ULD EE SENT TO THE FOLLOWING ADDDRES
NC DEQ I D R 1 NPDE
1617 Mail Service Center
Raleigh, North Carolina 7699-1617
Version 1112017