NCG060037_Name-Owner Change Form Page 2_20230328

NPDES Stormwater Permit Name/Ownership Change
Page 2 of 2
Ill. PERMIT AND FACILITY CONTACT INFORMATION
8. New permit contact's name and title: 11 r
(Permit Contact)
s coo Td;h A6 c
(Title)
9. Mailing address: IVA City: urL® e
State: MC Zip Code: Phone- ( 70-f -56141
Email address: S� 14f-kLa) 04 rcA Q)A.4, �(L-0M,
10. New facility.contacVs name and title: ®66j� qc)�
(Facility Contact)
AMg45el°
(Title)
11. Mailing address: 3WO Oes4 6yse Wj City: C�gir!n
State: _ Zip Code: al a73 _ Phone:( ?'O`f ) S[Q iq
E-mail address: i a,)SC' (%t(_G� (_0 K')®l . Low,,
12. New billing contact's name: Ac bmc� U(1_1 —LC
®® (Billing Contact) f
13. Mailing address: 77 � cll er !)r_„ )!? city:
State: C Zip Code: Oga-17 Phone: ( )
E-mail address:
iv, FACILITY ACTIVITIES AND DISCHARGE INFORMATION
1. Will in ustrial activities at the facility remain the same as under the previous Owner?
Yes M No ❑
2. Will the stormwater discharge location(s) remain the same? Yes Cf/No ❑
NOTE: if either of these questions is answered"No,"then more information is needed to review
the request. Please attach documentation to describe and explain the changes to the facility
activities,stormwater discharges, and/or outfall location. Depending on the information
provided, the Division may require that the new owner fife a new permit application.
Last Revised 3/13/2022