NCG590002_Owner (Affiliation Change)_20231214

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ROY COOPER `•„ "{3:
Covet-nor
ELIZABETH S.BMSER �✓� C
Secretary 4...,_ 4--
RICHARD E.ROGERS,JR. NORTH CAROLINA
DInctar Environmental Quality
PERMIT NAME/OWNERSHIP CHANGE FORM
I. CURRENT PERMIT INFORMATION:
Permit Number: NCO° I l I / or NCG5 (=I/6 / 0/0/ Z
1. Facility Name: a t `L'-.( IN Q...t\, 4 2-
•
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 c
,,i
✓/c. Other(please explain): OW Oe f— 4-c c[ I I ctAil t IA ty tt(e
2. New owner's
name (name to be put on permit):
OWEPJ 5TRMCXLA OP Jr
3. New owner's or signing official's name and title:ic ----
(Person legally responsible for permit)
MAYOR
(Title)
4. Mailing address: £e3. ig 0 K T'O City: Ba i I eAf
State:IJ E Zip Code: Z 7 g 07 Phone: (2 52 ) Z 3 - `i 9 77
E-mail address: tA0tPltAts+ +bPO4t9wt^ o-P'b tItk..jhc',, 8t45
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]
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Not512 North
Carolina Dep Sheet
1 Ett7 Maincntal Qce Cent 1 Division of,North
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Q 512 North Salisbury Strcct i 1617 Mail Service Center i Raleigh,Vomit Carolina 2l699.1617
m grea 919.707.9000
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Page 2 of 2
Applicant's Certification:1
I, OIOE,J 1"1•craxo<eitii J1- , 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:del Date: 12113/23
THE COMPLETED APPLICATION PACKAGE, INCLUDING ALL SUPPORTING
INFORMATION & MATERIALS, SHOULD SE SENT TO THE FOLLOWING ADDDRESS:
NC DEQ 1 DWR/ NPDES
1617 Mail Service Center
Raleigh, NC 27699.1617