NCG550563_owner (name change)_20230314

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NCDENR
North Carolina Department of environment and Natural Resources
Division of Water Resources
WATER QUALITY PERMITTING SECTION
PERMIT NAME/OWNERSHIP CHANGE REQUEST
This form is rol- ownership changes or name changes of NI'DIS waste%�Mcr permits.
• "I'erminee" r0brences,the existing permit holder
• "Applicant" references the entity applying Im the m%nership nanlc change.
1. N PDES Permit No. U„- which the change is Y-equesteln: N C O U
or
Certificate of Coverage #: N C G 5 5
IL Existing Permittee Information:
a. Permit issued to (company name):
b. Person legally responsible for permit:
First MI
Last
Titles ---
Permit Holder Mailing Address
City State Zip
Phone Fax
c. Facility name:
d. Facility's physical address: 4;2 VA —
Address
/OCI A-777q
City State Zip y
e. Facility contact person: R (6;0A r yf 400
First A Last Phone
II1. Applicant Information:
a. Request for change is a result of:
If other please eiplaln:
b. Permit issued to (company name):
c. Person legally responsible for permit:
® Change in ownership of the facility
❑ Name change of the facility or owner
First MI Last
n Permit Holder Mailing Address
l"
City State Zip
Phone E-mail Add ess
P.. Y ..1' l 1) ... 1 - . - 11. 1 0

d. Facility name:
OVA
C. Facility's physical address: P o u4 Dubhi A
Address
C4&,Vw
State Zip
person:f. Facility contacs person: /'s
First MI Last
Ql�.h'1Qr
Title
(C114) ag 1 14& 1 U J)u.h&.rw . % @ a l.u'"-%
Phone E-mail Address
IV. Will the permitted facility continue to conduct the same commercial/industrial activities conducted prior to
this ownership or name change?
® Yes
❑ No (please explain)
If applicable, the applicant shall submit a major permit modification request to DWR. A major modification shall be
defined as one that increases the volume, increases the pollutant load, results in a significant relocation of the
discharge point, or results in a change in the characteristics of the waste generated.
V. Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS ARE
INCOMPLETE OR MISSING:
1. This completed application is required for both name change and/or ownership change requests.
2- Legal documentation of the transfer of ownership (such as relevant pages of a contract deed, or a bill of sale) is
required for an ownership change request- Articles of incorporation are not sufficient for an ownership change.
Applicable regulations' 40 CFR t22.41, 40 CFR 122,61 and 15A NCAC 02H .0114
...................................................................................................................
The certifications below must be completed and signed by both the permit holder prior to the change (Permittee), and the
new applicant in the case of an ownership change request- For a name change request, the signed Applicant's Certification
is sufficient.
PERMITTEE CERTIFICATION (Permit holder prior to ownership change):
I, , 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 pa4.kage will be returned as incomplete -
Signature
APPLICANT CERTIFICATION
Date
1, , attest that this application for a namerownership 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.
igWture Date
tvW v
PLEASE SEND THE COMPLETE APPLICATION PACKAGE TO:
Division of Water Resources
Water Quality Permitting Section
1617 Mail Service Center
Raleigh; North -Carolina 27699-1617
NPDES PERMIT NAME/OWNERSHIP ('RANGE REQUEST
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Durham County, NC Property Report 3/14/2023
Parcel information
PIN:
0842-27-67-0280
Parcel ID:
160531
Acreage:
0.629
Land Use:
IND/ RES IMPROV
Deed Book:
007775
Deed Page:
000052
Plat Book:
000000
Plat Page:
000000
Subdivision:
PROP-KIRKLAND W B
Site Address:
2809 DUBLIN ST
Owner Name: WALL HARVEY A III
Owner Address:
2809 DUBLIN ST
Land Value:
$25,160.00
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Total Value:
$135,785.00
DURHAM , NC 27704
Building Value:
$110,625.00
Sale Price:
$120,000.00
Tax Maps are not to be used
to establish boundaries and/or size. Use for such is soley the reponsibilky of the user.