NC0023981_Owner (Affiliation Change)_20240415

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ROY COOPER
Governor
ELIZABETH S.BISEP_ `� "�+.�"
Secretary
RICHARD E.ROGERS.JR. NORTH CAROLINA
Director Environmental Quality
PERMIT NAME/OWNERSHIP CHANGE FORM
I. CURRENT PERMIT INFORMATION:
Permit Number: NCO° 4/4/1/6/4 or NCG5 / I I /
1. Facility Name: George L. Bernhardt, Sr. Lake Rhodhiss Water Treatment Plant
I!. 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
X c. Other(please explain):Retirement of Radford Thomas, signing official
VreI)9239814-WOCSOdb35
2. New owner's name(name to be put on permit):
City of Lenoir
3. New owner's or signing official's name and title: Dr. Jeff Church
(Person legally responsible for permit)
Public Utilities Director
(Title)
4. Mailing address: PO Box 958 City: Lenoir
State: NC Zip Code: 28645-0958 Phone: [phone]
E-mail address:ieff.church(a�ci.lenoir.nc.us
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]
South C'atofiaa Department of but irontnentiil Quality i Division of Waicr Resources
awi..i 3�Sj 512 Noah Salisbm}S3teet 11617\)ail Sol ice Centel I Raleigh.North Carolina 27699-1617
G�.•r.-,_._•"C:zmra^h:Oti 919 707.9011U

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Applicant's Certification:
1, Jeff Church , 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: _\ 1 s Date: / a`i
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, NC 27699-1617