NC0066958_Signature Authority_20221108

ROY COOPER
MICHAEL S. REGAN
LINDA CULPLPPI R
Water Resources
E VINONMEN) AL QUAErt
PERMIT NAME/OWNERSHIP CHANGE FORM
CURRENT PERMIT INFORMATION:
Permit Number: NCOO / /] or NCG5
1. Facility Name:T)1t.-4:e.- tdC 5c
U. 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
Vc. Other (please explain): VQS?(M
2. New owner's name (name to be put on permit)
. New owners or signing official's name and title:D:to& A-v-er5
(Person legall responsible for permit)
p en.n4-ende rt-t-
(Title)
Mailing address: kto (-1-0 F-ci City:
TH Phone: (5"Mc ) 2;436, (91
State: NC- Zip Code:
E-mail address: d \ters e).61-)51en e L Or:5
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)
Stale of North Carolina 1 Environmental Quality! Water Resources
1617 Mail Service Center Raleigh. NC 27699-1617
919 807 6300 919-807-6389 FAX
https'fideq.ne.goviaboutidivisionsiwaier-resoureesiwater-resources-permitsAvastoater-branch;npdes-wa.stelvater-permits

NPOES Name 8 Ownership Change
Page 2 of 2
Applicant's Certification:
* I, Decoct_ L Av-e r5 , 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.
*Signature:
Date: 11 / 1ZZ
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

D. Responsible Official Signature
The Responsible Official, as identified in accordance with 49(Itt 1,22.2„ is the appropriate individual
with the authority to sign and submit reports for the organization.
rt, Dana t-
Agreement for ..ACtat,
3 (printed name). have the authority to enter into this
"i2x*1t-C C34 ((Avner/Organization Name).
Ectuatilu-)
I request thc NCDWR grant me and, if included in Sections C and E of this form, the named Submitter(s),
an electronic signature credential to submit and accept documents electronically on behalf of my
organization.
I acknowledge that I, and the individual(s) named in Sections C and E (ifapplicable), work at/for my
organization and have authority to submit and accept electronic documents and act as a signatory for
purposes of the NCDWR's electronic document systems.
By submitting this application, I, .—Daleeta I-- • rs (printed name). have read,
understand, and accept the terms and conditions of this Electronic Signature Agreement I certify under
penalty of law that I have personally examined and am familiar with the information submitted in this
application and all attachments and that. based on my inquiry of those persons immediately responsible
for (Attaining the information contained in the application. I believe that the information is true, accurate
and complete. I am aware that there are significant penalties for submitting false information, including
the possibility of fine and imprisonment.
Responsible Official Sign
eta rs0" c
Title Date
1 • f3d15-5t3b-31 I
Email Address Phone Number
*email will he the primary method nfcontact far the electronic submittal process so it is important to have an accurate email
available at all times
IF you are a current eDMR submitter please provide your User Id:
User Id
Subscribed and sworn to before me this 'aff". day of r`inteitA—be,f— 20
(SEAL)
Signature ofNoiary Public
e 1.-•
Printed Name of Notary Public
My Commission Expires: _
NCPWR Electronic Submittal Agreement Version 1
Page 4

Novcrnber
Wastewater Branch
Water Quality Permitting Section
Division of Water Resources
1617 Mail Service Center
Raleigh, NC 27699-1617
Subject: Delegation of Signature Authority
ENTER FACILITY NAME
NPDES Permit Number NC
To Whorn It May Concern:
By notice of this letter, I hereby delegate signatory authority to each of the following individuals for all
permit applications, discharge monitoring reports, and other information relating to the operations at
the subject facility as required by all applicable federal, state. and local environmental agencies
specifically with the requirements for signatory authority as specified in I5A NCAC 213,0506.
Individual #1
Individual #2 (if applicable)
If you have any questions regarding this le er, please feel free to contact me at Enter Email or Phone
Number.
Sincerely,
7 Authorized Signing Official's Name TX\r\c‘ 1:\
Authorized Signing Official's Title
Mailing Address 3c155 k Pa. () 1 kick N.) c, 2flc
Email Address CACA-te.-15 C.-, C._ r5cYx... k curY1
Office Phone +:32s_ bsu,_
Mobile Phone
cc:
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