WQCSD0003_Owner (Affiliation Change)_20231214

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ROY COOPER 7 ..1'r�-x.,-c. -
Governor Syr
ELIZABETH S.BISER .*. R
Secretary .,
RICHARD E.ROGERS,JR. NORTH CAROLINA
Director Environmental Quality
PERMIT NAME/OWNERSHIP CHANGE FORM
I. CURRENT PERMIT INFORMATION:
Permit Number: NCO° I / I / or NCG5 / l / / U-1 Q e S b p C} 0 3
1. Facility Name:
II. NEW OWNER/NAME INFORMATION:
1. This request'for a name change is a result of: •
a. Change in ownership of property/company •
b. Name change only n � �/
V.
c. Other(please explain): IOw ole-r- 4, -t-'1 f I c.i4413 pi, L.Lt LL3 e
2, New owner's name(name to be put on permit):
OJUEWY CAOpIE
3. New owner's or signing official's name and title: itoe,#t P-4"7174---
(Person legally responsible for permit)
_MAYOR
(Title)
4. Mailing address: E o. z ® X ECD City: Eck t t eA.1
State:Jai C Zip Code: 27$07 Phone: (Z S'2 ) Z 3 S - g 9 7 7
E-mail address: \vtPKiAi5iret.4bPt-6 IA)get orPb tiC .7In , etr5
THIS APPLICATION PACKAGE WILL NOT BE ACCEPTED BY THE DIVISION UNLESS ALL or THE
APPLICABLE ITEMS LISTED BELOW ARE INCLUDED WITH THE SUBMITTAL.
REQUIRED ITEMS:
1. This completed application form
2. Legal documentation of the transfer of ownership (such as a property deed, articles of
incorporation, or sales agreement)
[see reverse side of this page for signature requirements]
North Carolina Dcpartmont of Envirantneival Quality I Division of\Va[er Resources
. DE
QE 512 North Salisbury Slreet 11G17 t�•Inil Scttidce Center I RaleI h,Nol�ll Carolina 27699-1617
ivaiH cn;aaa� �/ 919.707,9000

Page 2 of 2
Applicant's Certification:
1, OWEN -!•S'TFcrC,a.ANPJE , 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.
Signature: Date: 12/13/23
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, NC 27699.1617