WQ0021532_Owner (Affiliation Change)_20231214

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ROY COOPER. I,�7< h ia n
Governor '' a:
ELIZABETH S.BISER n 1 y
Secretary
RICHARD E.ROGERS,JR, NORTH CAROLINA
Director Environmental Quality
PERMIT NAME/OWNERSHIP CHANGE FORM
I. CURRENT PERMIT INFORMATION:
Permit Number: NC00 I I I / or NCG5 l / / / (,t)Q 50 Z I S' 3 Z
1. Facility Name:
IL 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 21 lam, Ci( �,
V"c. Other(please explain): OW V - 4 c t tt i' �` r -` 1' ta .3
2. New owner's name (name to be put on permit):
0&E)4 'i• - ci<LAMP IL
3. New owners or signing official's name and title: A
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(Person legally responsible for permit)
/i%l WY0
(Title)
4. Mailing address: i3e 0. E 0 X Lk) City: Bo( 14 e-Ai
State:l\ C Zip Code: 27207 Phone: (25'2 ) Z3 ~ `i 977
E-mail address: CtArMt A( ,f ct.4-br&-6wc% ®-Pbc=tiiex( I,e.. €irn
THIS APPLICATION PACKAGE WILL NOT BE ACCEPTED BY THE DIVISION UNLESS ALL OF 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 Department of Environmental Quality I Division of Water Resources
512 Noah Salisbury Street 11617 Ivied Service Center I Raleigh,North Carolina 27699-i617
t+omt♦c 7twl DE.,,h1.0,,' 919307.9000

Page 2 of 2
Applicant's Certification:
I, 2EW /)RrcKLA P , 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: 121423
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
•