NCG550181_owner (name change)_20231012

!nN CIXVCR -19
CLIZARCTN �. Wti1.R
RK'HARU L. RIX:f R\ Ni
a]
e of Coverage (CoC)
RSH/P CHANGC ronf
11tlaeae enter the CM' number tin which the change is requested.
Certificate of Covera e
?leave provide the following for the requested change (revised CoC).
a- Request for change is a result of. ® Change in ownership of the residence/property
ljorherplease explain: ❑ Name change of the facility or owner
b. CoC will be issued to (person's name
or company name. if. pplicable):
c. Owner: person legally responsible for
CoC: AA—F—A IA( (Al:__
d. Facility name (if applicable):
e. Facility address:
f. Facility contact person:
[if different from Owner]
11- MI Lest
Tiile
2117 Bethlehem Church PH j
Ph— Email Address
Ill. Contact person (if different from the person legally responsible for the CoC)
-r.� rvme c���l;nnn.iwmum mrnm.nn�nr,�la pu,uolnroirion of w,nnrao.eurecn
D E �J%) sIi NON�YrINLur)9Yre1 i Inl)Mnll Surim ('anlnr Iaoleigh,Nal�l:niuluia.l6W-101"I

Page 2 of2
IV Will this permitted facility continue to discharge the same volume and type of wastewater as
prior to this ownership or name change?
IN Yes
❑ No (please explain)
V. Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS
ARE INCOMPLETE OR MISSING:
❑ This 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 re uired 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.
APtPIA, CANT CERTIFICATION
1, w:a , 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 is not included, this application package will be
returned as incomplete.
/� / ` ✓ 10112/2023
Signature Date
...................................
PLEASE SEND THE COMPLETE APPLICATION PACKAGE TO:
Mr. Charles H. Weaver
NC DEQ / D W R / NPDES
1617 Mail Service Center
Raleigh, NC 27699-1617
charles. [e-mail]

Espanol Contact Us Account Settings LOG OUT
LOAN INFORMATION
Thank you for your payment on 10/01/2023.
To see how your payment was applied please visit Loan Activity.
Loan Information as of Oct 12, 2023
Loan Type
Loan Number
Next Payment Amount
Next Payment Due Date
Original Principal Balance
Current Principal Balance
Property Address
Origination Date
Loan Maturity Date
Original Term
Remaining Term
Prepayment Penalty
Interest Rate Information
Tax and Interest Information (2022)
VA Residential
8205092451
$3,975.03
11/01/2023
$599,000.00
$595,842.94
2117 Bethlehem Church Rd
Reidsville, NC 27320
04/25/2023
05/01/2053
360 months
355 months
No
v
V
Equal Housing Opportunity © 2023 PennyMac Loan Services, LLC, 3043 Townsgate Rd, Suite 200, Westlake Village, CA 91361, 818-224-7442, NMLS ID # 35953. For licensing
information, go to:
oaaoRTuNiry www.nmisconsumeraccess.org.
Trade/service marks are the property of PennyMac Loan Services, LLC and/or its subsidiaries or affiliates.
NMLS Consumer Access I Privacy I Forms I Legal I Do Not Sell or Share My Personal Information
Notice at Collection for CA Residents sl 7F.M.
Arizona Mortgage Banker License # 0911088. Licensed by the Department of Financial Protection and Innovation under the California Residential Mortgage Lending Act. Colorado
office: 5500 South Quebec Street, Suite 260 Greenwood Village, CO 80111, [phone]. Massachusetts Mortgage Lender License # MC35953. Minnesota: This is not an offer to
enter into an agreement and an offer may only be made pursuant to Minn. Stat. §47.206 (3) & (4). Licensed by the N.J. Department of Banking and Insurance. Licensed Mortgage
Banker-NYS Department of Financial Services. North Carolina Permit No. 119504607, 119505929, 119506567, 119506570, 119507419. Rhode Island Licensed Lender # 20092600LL,
Loan Broker, and Third Party Loan Servicer. Texas office: 2201 W. Plano Parkway, Suites 150 and 300, Plano, TX 75075. For more information, review Pennymac's state licenses and
important notices. Co-op loans not available. Some products may not be available in all states. Information, rates and pricing are subject to change without prior notice at the sole
discretion of PennyMac Loan Services, LLC. All loan programs subject to borrowers meeting appropriate underwriting conditions. This is not a commitment to lend. Other
restrictions apply. (0 1 -2023)
1/2