NCG550009_owner (name change)_20231211

_ -
RdY COOPER � f
Governor
ELIZABETH S. BISER �+
Secretary
RICHARD E. ROGERS, JR. NORTH CARot_INA
Director Env4rantnental Quality
'NPDES Certificate of Coverage (COC)
NCG550000 OWNERSHIP CHANGE FORM
I. Please enter the CoC number for which the change is requested.
Certificate of Coverage
N I C I G 15 15 Fj
U. Please provide the following for the requested change (revised CoC).
a. Request for change is a result of Change in ownership of the residence/property
`Q Name change of the facility or owner
If other please explain:
b. CoC will be issued to (person's name
or company name, if applicable):
c. Owner: person legally responsible for
CoC:
d. Facility name (if applicable):.
e. Facility address:
l i�ar 1 ' 5
First MI Last
Title
31 -Fre=uAk LG�Yic
Permit Holder Mailing Address
ress
a$ -7/4
city State Zip
c$ )' -45 -7 4
Phone E-mail Addre
Address
City State Zip
f. Facility contact person:
(if different from Owner] First MI Last
Phone E-mail Address
III. Contact person (if different from the person legally responsible for the CoC)
First MI Last
Title
Mailing Address
city State Zip
Phone E-mail Address
North Carolina Department of Environmental Quality I Division of Water Resources
R
E 512 North Salisbury Street 1 1617 Mail Service Center I Raleigh, North Carolina 27699-1617
nroktticat.xsrva
„�� 919.707.9000

Page 2 of 2
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Will this permitted facility continue to discharge the same volume and type of wastewater as
prior to this ownership or name change!
Yes
❑ No (please explain)
V. Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS
ARE INCOMPLETE OR MISSING:
Ej This completed application is required for both facility -name change and/or facility ownership
change requests.
❑ Legal documentation of the transfer of ownership (such as a property deed, relevant pages of a
contract, or a bill of sale) is required for an ownership change request.
......................................................................................................................
The certifications below must be completed and signed by the new applicant in the case of an ownership
change request.
APPLICANT CERTIFICATION
I, , 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 is not included, this application package will be
returned as incomplete.
Signature Date
PLEASE SEND THE COMPLETE APPLICATION PACKAGE TO:
Mr. Charles H. Weaver
NC DEQ / DWR / NPDES
1617 Mail Service Center
Raleigh, NC 27699-1617
[e-mail]