WI0500013_Application Attachment_20231001 (2)

I.
North Carolina Department of Environmental Quality
Division of Water Resources
PERMIT NAME/OWNERSHIP CHANGE APPLICATION FORM
1. Complete this form in its entirety as follows:
(a) Change of Ownership - Provide the information in Parts II and III and submit legal documentation of the
transfer of ownership such as a contract, deed, article of incorporation, etc. The certifications in part IV
must be signed by both the current permit holder, if available, and the new applicant(s).
(b) Name Change Only - Provide the information in Parts II and III. Sign the certification for the new
applicant in part IV.2.
2. Submit the properly completed form to the address on bottom of Page 2.
II. CURRENT PERMIT INFORMATION
1. Permit Number: W r p5L- C3O<Dt 3
2. Permitteename(s): J2-1PCr CT-r-1A (N-Z<--.�Lv {
3. For Business/Governmental Agency- Permit signing official's name and title:
(Person legally responsible forpermit)
4. Mailing Address:
City: Q-1 i-k� Ll State: }J C - Zip:
Telephone number: (-al ) 1?83 42-zo Fax number: (
EMAIL Address: Ldicc-\1e-Cr1-P-rej*A f n Q"5f V---'\ k 'C-9f1
5. Physical Address of Facility/Well(s) (if different than mailing address)
City:
III. NEW OWNER / NAME INFORMATION
County:
1. This request for a permit change is a result of:
_ a. Change in ownership of property/company
_b. Name change only
Zip:
_ c. Other (please explain):yg -\-0 -Li u , J e(X-' C'�-(, ^C,-
t ,V Z c`AQZL CAL `EeLg V,", o Jac I caAcA csx 11 hz C3-(ZC
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OCT 012Q2 .
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Permit/Name Change of Ownership Form Rev. 2-18-2020 Page 1

2. New Owner's name(s) as listed on the property deed (Please Print/or Type):
3. If Business or Governmental Agency- Permit signing official's name and title:
(Person legally responsible forpermit)
4. Mailing Address: 11 I k \ s-r _
City: kA LL State: �QC- Zip: - :-5( to
Day/Cell Phone No. Z( q-\) gTY3 - Lk-z-z 3 Fax number: �)
EMAIL Address: fr VV,111 l • C¢�
IV. CERTIFICATION
1. Current Permittee's Certification (Please print or type):
I, Tgipgfi.+Y ab�rne£\rc%sttest that this application for 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 arenot included,
this application package will be returned as incomplete. I understand I will continue to be responsible for
compliance with the current permit until a new permit is issued.
New Applicant(s)'s Certification (Please print or type):
I/We, ��`� Yrc�►vac-{ , attest that this application for
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 further
certify that I will operate and maintain the permitted facility in accordance with the permit and related regulatory
requirements.
Signature: Date:
Signature: Date: Oct I
SUBMIT THE COMPLETE APPLICATION PACKAGE VIA ONE OF THE FOLLOWING METHODS:
U.S. Postal Service:
Ground Water Resources Section
Courier / Special Delivery / In Person:
Ground Water Resources Section
NC Division Of Water Resources NC Division Of Water Resources
1636 Mail Service Center 512 North Salisbury Street
(AEI&, NC 27699-1636 Raleigh, NC 27604
OCT U 1 2023 Telephone Number: [phone]
i%X DEQ/DWR
Central Office
Permit/Name Change of Ownership Form Rev. 2-18-2020 Page 2