NCG551645_Owner (name Change)_20240125

ROY COOPER
Governor
ELIZABETH S, BISER
Secretary
S. DANIEL SMITH
Director
NORTH CAROLINA
Environmental 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 C I G 5 1 5
II. Please provide the following for the requested change (revised CoC).
a. Request for change is a result of Q'Change in ownership of the residence/property
❑ 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: 1
First MI Last
Title
Permit Holder Mailing Address
City State Zip
►� 2�l�rl Se
Phone E-mail Address
d. Facility name (if applicable):
e. Facility address:
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 Ml Last
Title
Mailing Address
City State Zip
Phone E-mail Address
tg;mu
E�..�j North Carolina Department of Environmental Quality { Division of Water Resources
, /� 512 North Salisbury Street 11617 Mall Service Center I Raleigh, North Carolina 27699-1617
c 919.707.9000