WQ0023310_Other Correspondence_20221229

ROY COOPER S
Governor '
ELIZABETH S.BISER .��, /-
Secretary * -.
S.DANIEL SMITH NORTH CAROLINA
Director Environmental Quality
NPDES Certificate of Coverage (CoC)
NCG550000 OWNERSHIP CHANGE FORM
I. Please enter the CoC number for which the change is requested.
Certificate of Coverage
N C G S 5 ` 3 i' t)
II. Please provide the following for the requested change(revised CoC).
a. Request for change is a result of: ❑ Change in ownership of the residence/property
❑ Name change of the facility or owner
If other please explain: 0l„na1 fal`1tiny add rtss cA.41941 &vd emo LI ctidi f
b. CoC will be issued to(person's name
or company name, if applicable):
c. Owner: person legally responsible for
CoC: b.ert rr\ /'D t,, r•N
First MI Last
RECEIVED Title
G292022 Po goy i is.
Permit Holder Mailing Address
CDEQID1NRINPDES D r u �, " 7 a -- l a.I ¶
City State Zip
( ��� ) 67� 'Sy1 �� r' mbI-04.1t7q® ma;'. co1y\
Phone E-mail Address
d. Facility name(if applicable):
e. Facility address: —7 I I S 1t'1 a he tv S (n0 a€
Address
puritan\ hIL g.77/ X—
City State Zip
f. Facility contact person:
[if different from Owner] First MI Last
( )
Phone E-mail Address
III. Contact person (if different from the person legally responsible for the CoC)
First MI Last
Title
Mailing Address
City State Zip
( )
Phone E-mail Address
�D —It) North Carolina Department of Environmental Quality I Division of Water Resources E 512 North Salisbury Street 11617 Mail Service Center I Raleigh,North Carolina 27699-1617
I.YvP1 H CA3,01.INA
oaatto.0 a En.iro+1+.m.1 Wass /"" 919.707.9000
I

NCG550000 OWNERSHIP CHANGE FORM
.
Page 2 of 2
IV Will this permitted facility continue to discharge the same volume and type of wastewater as
prior to this ownership or name change?
Yes
❑ No(please explain)
V. Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS
ARE INCOMPLETE OR MISSING:
❑ This completed application is required for both facility-name change and/or facility ownership
change requests.
❑ Legal documentation of the transfer of ownership(such as a property deed,relevant pages of a
contract,or a bill of sale)is required for an ownership change request.
The certifications below must be completed and signed by the new applicant in the case of an ownership
change request.
APPL CANT CERTIFICATION
I,17 1. attest that this application for a name/ownership change has been reviewed and is accurate and
c.mplete 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 is not included,this application package will be
returned as incomplete.
044-4): 4-44a- a0 aOa �
tore to
PLEASE SEND THE COMPLETE APPLICATION PACKAGE TO:
Mr.Charles H.Weaver
NC DEQ/DWR/NPDES
1617 Mail Service Center
Raleigh,NC 27699-1617
[e-mail]