NCG500047_Owner (Affiliation Change)_20230512

EIVEDROY COOPER "'_i �.' 7� ', E RED
Governor ;, Jai„',`, '' '
DIONNE DELLI-GATTI n�{% ,1 I. 2 2023
Secretary
Director Environmental Quality SMITH NORTH CAROLINA NCDEC IDWRINPDES
PERMIT NAME/'OWNERSHIP CHANGE FORM .
I. CURRENT PERMIT INFORMATIS N: •
Permit Number: NCOO /
/ / / or NCO5O /O /O/A/ 7
1. Facility Name: C.`odict,rvJ CDr f o(Lv+/-0 n
IL 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 (�
X c. Other(please explain): 9er$ONI e I nv,v�, es - I,,)eto oc't'�C1a 1r
2. New owner's name(name to be put on permit):
N/A
3. New owner's or signing official's name and title: �0.r\ 9O140.
(Person legally responsible for permit)
S 4e 1,40,Aaqer'
(Titl€)
4. Mailing address: CoaS E. C.Lk-&uibk Ave. City: RooNk 00(!y
State: N.)C Zip Code: aY 1 20 Phone: (70q ) zaa- ao-,ti
E-mail address: J0.n ,boflna P C,1ati 0.r1 r1 , C0ill
THIS APPLICATION PACKAGE WILL NOT ::E 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]
DE --"A
North Carolina Department of Environmental Quality I Division of Water Resources
512 North Salisbury Street 11617 Mail Service Center I Raleigh,North Carolina 27699-1617
NOPTH CAROLINA
o,nammem m o m Ownry 400*/ 919.707.9000

NPDES Name&Ownership Change
Page 2 of 2
Applicant's Certification:
I, '0.n zO 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 and attachments are not included, this application package will be returned as
incomplete.
Signature: Date: 0? O 3
THE COMPLETED APPLICATION PACKAGE, INCI rU ING ALL SUPPORTING
INFORMATION MATERIALS, SHOULD :LE SENT TO THE FOLLOWING ADDDRESS:
NC IDEQ /DWR/NPDES
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
•
Version 11/2020