NCG550722_Permit Name/Ownership Change Form_20230607

RECTIVEDIC DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF WATER RESOURCES
JU`i 0 7 2023
WATER QUALITY PERMITTING SECTION
NPDES PERMITTING
NORTH CAROLINA PERMIT�I'�IQA96' W,MC1)r 4AGE FORM
Environmental Quality
CURRENT PERMIT INFORMATION:
Permit Number: NC00�_/��_ or NCG55/_�q/_j/_�/ 2
1. Facility Name: 23 MtaAdLU �y-IVe /'BUnG0-m6e WUytTtl
NEW OWNER/NAME INFORMATION:
1. This request for a name change is a result of:
V a. Change in ownership of property/company
b. Name change only
c. Other (please explain):
2. New owner's name (name to be put on permit): 1'�
�G�7Yl tyik e- C:2 ! C aeLr
3. New owner's or signing official's name and title: ka*fLKjhe_
(Person legally Wrs.
onsible for permit)
(Title)
4. Mailing address: 23 Mul�w'By-,oc - DIr City: RQ rt ,eV
State: /VCI Zip Code: 287 32
E-mail address:
FACILITY AND DISCHARGE INFORMATION
Phone: ( 764 ) 210— g7-35
1. Will the waste stream for the facility remain the same asunder the previous owner. Yes No
2. Will the treatment system and discharge location remain the same? P
No
"No Responses"
If either or both of these questions are answered "No" then more information will be needed to review the
request. Please attach documentation to describe and explain the changes to the facility activities, waste
stream, treatment process or outfall location. The Division may not be able to process the Permit
Name/Ownership Change request and may require that the new owner file a new permit application.
D E Q North Carolina Department of Environmental Quality I Division of Water Quality
ero::f
Nomri cnRa_xan
�, 512 North Salisbury Street 1 1617 Mail Service Center I Raleigh, North Carolina 27699-1617
919.707.9000

NPDES Name and Ownership Change
Page 2 of 2
THIS APPLICATION PACKAGE WILL NOT BE ACCEPTED BY THE DIVISION UNLESS ALL OF THE
APPLICABLE ITEMS LISTED BELOW ARE INCLUDED WITH THE SUBMITTAL.
REQUIRED ITEMS:
This completed application form
Legal documentation of the transfer of ownership (such as a property deed, articles of
incorporation, or sales agreement)
Information to document facility, waste stream, treatment system or outfall changes as noted in
item III above (if appropriate)
Applicant's Certification:
e l�l� ��i/l 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. I understand that Permit Name/Ownership Change can only take place through action
taken by the Division of Water Resources and that no actions on my part or the part of my company
result in the automatic transfer of permit coverage.
Signature: Date: W417--j!V-3
THE COMPLETED APPLICATION PACKAGE, INCLUDING ALL SUPPORTING INFORMATION & MATERIALS,
SHOULD BE SENT TO THE FOLLOWING ADDDRESS:
NC DEQ / DWR / NPDES
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Version 07/2021

Type: CONSOLIDATED REAL PROPERTY
Recorded: 4/21/2023 3:41:13 PM
Fee Amt: $1,506.00 Page 1 of 5
Revenue Tax: $1,480.00
Buncombe County, NC
Drew Reisinger Register of Deeds
BK 6312 PG 1911 - 1915
There are no delinquent taxes that are a lien
the parcel(s) described in the deed which the
Buncombe County Tax Collector is charged
with collecting.) L
04-21-2023
Date D 0 y Tax Coilector
NORTH CAROLINA GENERAL WARRANTY DEED
Excise Tax: $1,480.00
Parcel No, 9675-79-8713
Prepared by: The Brock Law Firm, PLLC. Annika M. Brock, a licensed NC attorney, 26 N. Liberty Street. Asheville,
NC 28801 (Box 27)
Return to: Worley & Peltz. PLLC42 Orchard Street, Asheville, NC 28801,
Brief description for the Index: 23 Meadow Brook Drive, Fletcher, NC 28732
THIS DEED made this Lo day of April, 2023, by and between
GRANTOR
Kimberly S. Long, Trustee of the
Kimberly S. Long Trust U/A/D August 19,
2016, and any amendments thereto
104 West Lake Avenue
Hendersonville, NC 28739
GRANTEE
Jeff rey Giezen and Katherine Giezen,
married to each other
23 Meadow Brook Drive
Fletcher, NC 28732
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 Grantor, for a valuable consideration paid by Grantee, the receipt ofwhich is hereby acknowledged,
has and by these presents does grant, bargain, sell and convey unto Grantee in fee simple, all that certain lot or parcel of
land situated in Buncombe County, North Carolina and more particularly described as follows (the "Property"):
SEE EXHIBIT A, ATTACHED HERETO AND INCORPORATED HEREIN BY THIS REFERNCE.
SEE EXHIBIT B, ATTACHED HERETO AND INCORPORATED HEREIN BY THIS REFERNCE.
This instrument prepared by Annika M. Brock a licensed NC attorney. Delinquent taxes, if any, tobe paid by the closing
attorney to the County Tax Collector upon disbursement of closing proceeds.
The Property was acquired by the Grantor by instrument recorded in Book 5832, Page 1827, Buncombe County
Registry.
The Property does include the primary residence of Grantor.
No title examination requested or conducted by the preparer of this deed.
submitted electronically by "Worley & Peltz, PLLC"
In compliance with North Carolina statutes governing recordable documents
and the terms of the submitter agreement with the Buncombe county Register of Deeds.

TO HAVE AND TO HOLD the Property and all privileges and appurtenances thereto belonging to Grantee in fee
simple.
And Grantor covenants with Grantee, that Grantor is seized of the Property 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 the title against the lawful claims of all persons whomsoever, other than the following exceptions:
Utilities physically located on the Property, ad valorem taxes for the current year and subsequent years, easements and
restrictions of record.
IN WITNESS WHEREOF, Grantor has duty executed the foregoing as of the day and year first above written.
(SEAL)
Kimberly S. LoAX, Trustee oft Kimberly S. Long
Trust U/A/D A ust 19, 2016
STATE OF NORTH CAROLINA
COUNTY OF BUNCOMBE
I, the undersigned notary public of the aforesaid jurisdiction, certify that Kimberly S. Long, Trustee of the
Kimberly S. Long Trust U/A/D August 19, 2016, personally appeared before me this day and, having produced
adequate proof of identity, acknowledged the due execution of the foregoing instrument for the purposes therein
expressed. Witness my hand and Notarial stamp or seal this ?day of April, 23.
My Commission Expires: 1 i -,A _13
otary Public)
ANNIKA M. BROCK Print Name: /` uAL ik%- tot &-
public. North Carolina
Notary be County
Buncom x fires
MY Commission �023
November 1o,

EXHIBIT "A"
LYING IN BUNCOMBE COUNTY, NORTH CAROLINA
BEING ALL of Lot 52 as shown on that plat of Meadwood recorded in Plat Book 59, at Page 132,
of the Buncombe County, NC Register's Office, reference to which Plat is hereby made for a more
particular description of said Property.
AND BEING all of that property described in that deed recorded in Deed Book 5832, at Page
1827, in the Buncombe County Register of Deeds.
TOGETHER WITH AND SUBJECT TO all easements, rights of way, conditions, covenants, and
restrictions appurtenant to the property described above.
(23-00205 Giezen)
RECEIVED
J U." -0 7 2 023
NCDEQ/DWR/NPDES

EXHIBIT B
Prepared by and return to:
The Brock Law Firm, PLLC, Annika M. Brock, Esq. (Box 27)
Certification of Trust for the Kimberly S. Long Trust U/A/D August 19, 2016
Pursuant to North Carolina General Statute, this Certification of Trust is signed by Kimberly S.
Long, Trustee of the Kimberly S. Long Trust U/A/D August 19, 2016.
1. Kimberly S. Long ("Settlor") created that certain trust known as the Kimberly S. Long Trust U/A/D
August 19, 2016.
2. The Trust was amended on June 30, 2021, November 8, 2019, and January 27, 2021.
3. The current Trustee's name and address are Kimberly S. Long, 104 West Lake Avenue,
Hendersonville, NC 28739.
4. The tax identification number of the trust is available upon request.
Title to assets held in the Trust shall be titled as:
Kimberly S. Long, Trustee of the Kimberly S. Long Trust, U/A/D August 19, 2016.
6. Any alternative description shall be effective to title assets in the name of the Trust or to designate the
Trust as a beneficiary if the description includes the name of at least one initial or successor trustee,
any reference indicating that property is being held in a fiduciary capacity, and the date of the Trust.
7. The powers of the Trustee include the power to acquire, sell, assign, convey, pledge, encumber, lease,
borrow, manage and deal with real and personal property interests.
8. The Trust has not been revoked, modified or amended in any manner that would cause the
representations in this Certification of Trust to be incorrect.
9. The undersigned intends for this Certification to comply with NCGS §36C-10-1013. The undersigned
further intend for this Certification to be relied upon by third parties and intend that such third parties
may conclusively rely upon the accuracy of the statements set forth herein and may also conclusively
assume the existence of the facts set forth herein.

Certification of Trust for the Kimberly S. Long Trust U/A/D August 19, 2016
This the ? 0 day of April, 2023.
-" Xy ��
t
Kimberly S. Lon , Trustee oft Kimberly S. Long Trust
U/A/D August 19, 2016
STATE OF NORTH CAROLINA
COUNTY OF BUNCOMBE
1, a Notary Public, certify that, Kimberly S. Long, Trustee of the Kimberly S. Long Trust U/A/D
August 19, 20I6 personally appeared before me this day and acknowledged the due execution of the
foregoing instrument for the purposes therein expressed. Witness my hand and official seal this -ZLL day of
April, 2023.
"d ANNIKA M. 8ROCK
Notary Public, North Carolina
Not Pub is Buncombe County
My Commission Expires
My commission expires: 1. ta_� November 10, 2023