NC0033448_Owner (Affiliation Change)_20231228

NC DEPARTMENT OF ENVIRONMENTAL QUALITY
`"N
t • DIVISION OF WATER RESOURCES
• " WATER QUALITY PERMITTING SECTION
NORTH CAROLINA NPDES PERMITTING
Environmental Quality
PERMIT NAME/OWNERSHIP CHANGE FORM
CURRENT PERMIT INFORMATION:
Permit Number: NCO() 3 / 3 / 4 / 4 / $ or NCG5_/_/_/ /_
1. Facility Name: Uailet3 Creek Apck ,rner,i-S WW-CP
II. NEW OWNER/NAME INFORMATION: RECEIVED
1. This request for a name change is a result of: DEC 28
2023
a. Change in ownership of property/company
NCDEQ/DWR/NPDES
/ b. Name change only
c. Other(please explain): 'f`A6\11 &tdress CI�Anq�
0 New owner's name (name to be put on permit):
5 4- sit G-t-(---r p i )1 LC__- (no okrunod
3 New owner's or signing official's name and title: SCu't-ta,
(Person legally responsible ter permit)
(Title) VIQ
C�
Mailing address: aLd) Q MI WOLL1 Nay: 1Q (� eci —
State:6i Zip Code: ` ' (70 5 Phone:71L )Rq (�
E-mail addressaddress6 tAi PAI&LCt 'rl3C V►ah ic(.t I . urn
III. FACILITY AND DISCHARGE INFORMATION 44
1. Will the waste stream for the facility remain the same as under the previous owner? Yes'El/No ❑
2. Will the treatment system and discharge location remain the same? Yes 6d No ❑
"No Responses"
If either or both of these questions are answered"No"then more information will be needed to review the
request. Please attach documentation to describe and explain the changes to the facility activities, waste
stream, treatment process or outfall location. The Division may not be able to process the Permit
Name/Ownership Change request and may require that the new owner file a new permit application.
E Q:,V North Carolina Department of Environmental Quality I Division of Water Quality
J!/� 512 North Salisbury Street 11617 Mail Service Center I Raleigh,North Carolina 27699-1617
nOn EU
°tom�..tef"`E"`"" °"0�° 919.707.9000

NPDES Name and Ownership Change
Page 2 of 2
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:
VA This completed application form
2. Legal documentation of the transfer of ownership (such as a property deed, articles of
incorporation, or sales agreement)
3. Information to document facility,waste stream,treatment system or outfall changes as noted in
item III above (if appropriate)
Applicant'scertiicafion
I,3 c�0'1 r r r i n fl , attest that this application for a
name/ownership change has been review i 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. I understand that Permit Name/Ownership Change can only take place through action
taken by the Division of Water Resources and that no actions on my part or the part of my company
result in the automatic transfer of permit coverage.
Signature" GfL( e C�� Date 1 �✓ J
1
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, North Carolina 27699-1617
Version 07/2021