NCG030707_Name-Owner Change Application (Orig Upload)_20230509

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NC DEPARTMENT OF ENVIRONMENTAL QUALITY
r
DIVISION OF Energy, Mineral, and Land Resources
•r STORMWATER PROGRAM
NORTH CAROLINA
Environmental Quality
NPDES STORMWATER PERMIT NAME/OWNERSHIP CHANGE FORM
I. CURRENT PERMIT INFORMATION:
Permit Number: NCS�f_/�� / or NCG_!P_j / / / 2
1. Facility Name (prior to change):
It. NEW OWNER/NAME INFORMATION:
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2. This request for a name change is a result of:
a. Change in ownership of property/company
V/""'b. Name change only (Facility and/or Company)
c. Other (please explain):___,
(for example, facility address update. inchAe additional attachments if necessary.)
3. New owner's name (name, i be ptst oo permit as Permittee):
/1✓A. 1lso^
4. New owner's or signing officiai's name and title:
(Person legally responsible for permit)
FI4S /1VA4A for
(Title)
5. Mailing address: 1 g401 City: k-ie-tL,�[Ic
State: AIC_ Zip Code: Phone: ( 74 j 2�6fr6,
E-mail address: r ^�I. , /�:n�.� e,l Sor,�p•+ro�+-ti
6. New facility name (if applicable): A/e VSpn ('.7 lo64 &kkSy I 10
7. Effective date of transfer or name change: S C\ I
NorthCarolina Department of Environmental Quality I Division of Eneryy.Mineral and Land Resources
E 512 North Salisbut y Street I Ib12 Mail Service Center I Raleigh.North Carolina Z704 tb12
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am�•w" /�'� 919,707.9200

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NPDES Stormwater Permit Name/Ownership Change
Page 2 of 2
THIS APPLICATION PACKAGE WILL NOT BE ACCEPTED BY THE DIVISION UNLESS
ALL OF THE ITEMS LISTED BELOW ARE INCLUDED.
REQUIRED ITEMS:.
I. This completed application form (with original signature)
2. Legal documentation of transfer of ownership (such as relevant pages of a deed or a bill of sale) is
required for an ownership change request. Articles of incorporation are not sufficient for an
ownership change but can be provided for a name change.
3. Information to document facility, industrial activities, stormwater discharges, or outfall changes
as noted in item IV above (if appropriate)
Why is this information needed?
Regulations in 40 CFR §122.63 allow for minor modifications to NPDES permits for a change of
ownership or operational control of a facility, provided that information supports that no other change
in the permit are necessary.
Why does this form need to be mailed in?
Permittees and applicants must fulfill signatory requirements in the NPDES federal
regulations in 40 CFR §122.22 (please see those regulations for guidance). Until NCDEQ's
electronic submission process meets Cross-Media Electronic Reporting (CROMERR)
requirements, this original signed (not digital signature) form must be mailed to the
address below. The uploaded copy is stored as part of the permit record in the Division's
digital repository.
Applicant's Certification:
1 ; ,� �� ; n e/ , attest that th,:� z,,ppilcation for a name and/or ownership
change submitted has been reviewed and is ar'curale and complete to the best of my
knowledge. I understand that if all racpjiree. a:-;.rts of this application are not completed, or if all
required supporting information is not inn-laded, ;iris application package will be considered
incomplete and may be returned.
Date:
Signature:
THE COMPLETED APPLICATION AND ALL SUPPORTING INFORMATION SHOULD BE SENT TO:
DEMLR Stormwater Program
512 North Salisbury Street, 6`h Floor (Office 640K)
1612 Mail Service Center
Raleigh, NC 27699-1612
Last Revised 3/13/2022