NCGNE1426_Name-Owner Change Application_20230628

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4., '' `:.. NC DEPARTMENT OF ENVIRONMENTAL QUALITY
'� , ., N. "' DIVISION OF Energy, Mineral, and Land Resources
STORMWATER PROGRAM
NORTH CAROLINA
Environmental Quality
NPDES STORMWATER PERMIT NAME/OWNERSHIP CHANGE FORM
I. CURRENT PERMIT INFORMATION:
Permit Number: NCS / / / / /_ or NCG A / / / /((/ 2 / 4.
1. Facility Name (prior to change): L--Ik()')ccEN Ctf NquS. (?( E j t /`(e
II. NEW OWNER/NAME INFORMATION:
2. This request for a name change is a result of:
a. Change in ownership of property/company
—. Name change only (Facility and/or Company)
c. Other(please explain):
(for example,facility address update. Include additional attachments if necessary.)
3. New owner's name (name to be put on permit as Permittee):
.gAr-rl-'( (9 L- -(1)2eAJC; .1c2
4. New owner's or signing official's name and title: f, y 6 L a
(Person legally responsible for permit)
(5 U-)c`-% 6=rL
(Title)
5. Mailing address: PO &O fC /( v9 City: OWKA—.cOC
State: /Uri Zip Code: Z7341 Phone: ( 33(2 ) 3 6 2 — / q 3�
E-mail address: .6/'Z-5�0 A- .- , (49d4
6. New facility name (if applicable):
7. Effective date of transferor name change: l? — — Z 3
D E 4 North Carolina Department of Environmental Quality I Division of Energy.Mineral and Land Resources
512 North Salisbury Street 1 1612 Mail Service Center I Raleigh.North Carolina 27b99-1612
u + ,,m�;.o- wawm\ 919.707.9200