NCG550862_owner (name change)_20230220

ROY COOPER
Governor
ELIZABETH S. BISER
secretary
S. DANIEL SMITH
Director
NORTH CAROLINA
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
5
5
0
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:
b. CoC will be issued to (person's name
or company name, if applicable): etrlde-v f. (o J e rs
c. Owner: person legally responsible for
CoC: A I e,x allde�
First MI L st
d. Facility name (if applicable):
e. Facility address:
f. Facility contact person:
Title
S 3a olive 3 ranr,{it, R o act,
Permit Holder Mailing Address
Ditvki NC 07703
City State Zip
( `i (9) H 5 I - a V pt e. rs • a, I ex3a�'cl�iit 0o • fz v+'t
Phone -mail Address
nil A
NIA
Nlfl
City
Address
State Zip
[if different from Owner] First MI Last
Phone E-mail Address
III. Contact person (if different from the person legally responsible for the CoC)
Kayla. -K Rol evs
First MI tist
ow'n>m.� m �Jno�Aemn ma
Title
53a olive brar1clti 'oacL
Mailing Address
Rork)aw>. I\16 a 1-03
City State Zip
(911I)i0l'aE5 ci rocjers•V-c jI 3a@9marl-corn
Phone E-mail Address
North Carolina Department of Environmental Quality 1 Division of Water Resources
512 North Salisbury Street 1 1617 Mail Service Center 1 Raleigh. North Carolina 27699-1617
919.707.9000

NCG550000 OWNERSHIP CHANGE FORM
Page 2 of 2
IV.
V.
Will this permitted facility continue to discharge the same volume and type of wastewater as
prior to this ownership or name change?
IN Yes
❑ No (please explain)
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.
APPLICANT CERTIFICATION
I, Wog- , 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 is not included, this application package will be
returned as incomplete.
2.4-tk FibrccrrY 2023
4ignature Date
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]

Book9669 - Page 234 Page 1 of 2
For Registration Sharon A, Davis
Register of Deeds
Durham County, NC
Electronically Recorded
2022 Apr 14 03:31 PM
Book: 9669 Page: 234
NC Rev Stamp: $ 350.00 Fee: $ 26.00
Instrument Number: 2022015852
DEED
NORTH CAROLINA GENERAL WARRANTY DEED
Excise Tax: $350.00
Parcel Identifier No. 193386 Verified by County on the day of 20
By:
MailBox to: Alexander F. Rogers and wife, Kayla Rogers, 532 Olive Branch Road, Durham, NC 27703
This instrument was prepared by: North Carolina Real Estate Law Firm, 6739 Falls of the Neuse Road, Suite 201, Raleigh, NC 27615
Brief description for the Index:
THIS DEED made this 3 frn day of }r-rrr- 1 , 20 Z2, by and between
GRANTOR
Lisa Fletcher Rogers, unmarried
4009 Leah Lane
Durham, NC 27712
GRANTEE
Alexander F. Rogers and wife, Kayla Rogers
532 Olive Branch Road
Durham, NC 27703
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 that certain lot, parcel of land or
condominium unit situated in the City of Durham, Township, Durham County, North Carolina and more
particularly described as follows:
Being all of Lots 7 and 8, Block F, Shaw Hills Subdivision also known as Shaw Hills Estates, as recorded in Plat Book 54, Page 28,
Durham County Registry.
The property hereinabove described was acquired by Grantor by instrument recorded in Book 8628 page 63.
All or a portion of the property herein conveyed includes or \/ does not include the primary residence of a Grantor.
A map showing the above described property is recorded in Plat Book 54 page 28.
NC Bar Association Fonn No. 3 ei Revised 7/ 2013 North Carolina Bar Association - NC Bar Fonn No. 3
Printed by Agreement with the NC Bar Association North Carolina Association of Realtors, Inc. - Standard Form 3
Submitted electronically by "The North Carolina Real Estate Law Firm"
in compliance with North carolina statutes governing recordable documents
and the terms of the submitter agreement with the Durham county Register of Deeds.

Book9669 - Page 235 Page 2 of 2
TO HAVE AND TO HOLD the aforesaid lot or parcel 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 title is marketable and free and clear of all encumbrances, and that Grantor will warrant and defend thstalaafl 9st the
lawful claims of all persons whomsoever, other than the following exceptions: ``�`\P H R �STj Uzi
IN WITNESS WHEREOF, the Grantor has dulyexecuted the foregoingas of the dayandyear first above writte-0. C "'Ss10" ��cc'•92 : OTA9 ro^. p_
(S
�'9\' Z5-31.2 E O
Print/Type Name: Lisa Fletcher Ro
State of North Carolina — County of CLYN' ,-'0
I, the undersigned Notary Public of the County and State aforesaid, certify that Lisa Fletcher Rogers personally appeared
before me this day and acknowledged the I ue execution of the foregoing instrument for the purpose�c-tb&via expressed. witness my
hand and Notarial stamp or seal this I l 1 day of AfYl I , 20_
My Commission Expires: Ctz 31 '21P
NotaryPu
2
NC Bar Association Form No. 3 © 1976, Revised ® 1/1/2010, 2013 This standard form has been approved by.
Printed by Agreement with the NC Bar Association North Carolina Bar Association - NC Bar Form No. 3