NCG551074_Owner (Name Change)_20240318

`.. iE
RECEIVED
ROY COOPER
Governor e MAR 1 8 2024
ELIZABETH S.BISER
Secretary *4,0,0100
S.DANIEL SMITH NORTH CAROLINA NCDEQIDWR/NPDES
Director 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 G 5 5 1 0 7 4
II. 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
❑ 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): Ashley N. Dale
c. Owner: person legally responsible for
CoC: Katherine T Dale
I first MI Last
l itle
3632 Tanglebrook Trail
Pennit Holder Mailing Address
Clemmons NC 27012
( it\ State Zip
(336 ) 766-8962 [e-mail]
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)
Ashley N. Dale
First MI Last
l itle
1303 Goodwin Rd
Mailing Address
Durham NC 27712
City State Zip
(919 ) 673-5337 [e-mail]
Phone E-mail Address
D ' Carolina r of iom Quality { Di of Wt Re
512 NorthNorth SalisburyDepa Streettment 13617Env Mailr n Serviceental Center ( Raleigh,vision Northa Ca errolinasources 27b99 1b1
7
/"# 919.707.9000

NCG550000 OWNERSHIP CHANGE FORM
Page 2 of 2
l V Will this permitted facility continue to discharge the same volume and type of wastewater as
prior to this ownership or name change?
71 Yes
I No(please explain)
V. Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS
ARE INCOMPLETE OR MISSING:
❑ This completed application is required for both facility-name change and/or facility ownership
change requests.
® Legal documentation of the-transfer of ownershi (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, KD ,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..00 4. �I vV 6Z' AL Feb 29, 2024
Signature 6k! F 1 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]