NCG550019_Owner (Name Change)_20230817

ROY COOPER
ELIZABET H S. RISER
RICHARD E. R.OGERS, JR., NOR i i i. AP LiNA
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NPDES Certificate of Coverage (CoC)
NCG550000 OWNERSHIP CHANGE FORM
Please enter the CoC number for which the change is requested.
RECEIVED
�U6 I
NCDEQ/DWR%NPDES
Certificate of Coverage
N I C I G 15 1 5 1 C)
II. Please provide the following for the requested hange (revised CoC).
a. Request for change is a result of: Change in ownership of the residence/property
Name change of the facility or owner
If other please explain:
b. CoC will be issued to (person's name
or company name, if applicable):
c. Owner: person legally responsible for
CoC:
d. Facility name (if applicable):
e. Facility address:
Sco tt CS, sha�rtar.6
First MI Last
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l 1 Ga k to rot &n v P,
Permit Hold r Mai in Address t _ �.
City State Zip
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Phone E- it Address CQ ✓ri
Address
City State Zip
f. Facility contact person:
[if different from Owner] First MI Last
Phone E-mail Address
III. Contact person (if different from the person legally responsible for the CoC)
First MI Last
Title
Mailing Address
City State Zip
( )
Phone E-mail Address
j��� North Carolina Department of Environmental Quality I Division of Water Resources
512 North Salisbury Street 1 1617 Mail Service Center I Raleigh, North Carolina 27699-1617
�1 �,�/ 919.707.9000

IV
Page 2 of 2
Will this permitted facility continue to discharge the same volume and type of wastewater as
pno,r to this ownership or name change?
IKYes
No (please explain)
V. Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS
ARE INCOMPLETE OR MISSING:
❑ s completed application is required for both facility -name change and/or facility ownership
change requests.
Legal documentation of the transfer of ownership (such as a property deed, relevant pages of a
contract, or a bill of sale) is required for an ownership change request.
The certifications below must be completed and signed by the new applicant in the case of an ownership
change request.
APPLICANT CERTIFICATION
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 infation is not included, this application package will be
returned as incomplete. .
Signature
Date
PLEASE SEND THE COMPLETE APPLICATION PACKAGE TO:
Mr. Charles H. Weaver
NC DEQ / DWR / NPDES
1617 Mail Service Center
Raleigh, NC 27699-1617
[e-mail]