SW3170303_Change of Permittee Information_20240701

ULMLK USE ONLY
Date Received Fee Paid Permit Number
STATE STORMWATER:
PERMIT INFORMATION UPDATE APPLICATION FORM
There is NO FEE for updating project name or permittee information.
This form is to only to be used by the current permittee to notify the Division of:
1) changes to the Point of Contact(signing official) for the current permittee (LLC, Corporation, HOA or POA);
2) changes to the mailing address, phone number or email address of the current permittee;
3) changes to the name of the project;and
4) changes to the legal corporate name as documented by a Name Change or Merger filed with the NCSOS.
A. NEW PERMIT INFORMATION
State Stormwater Permit Number: SW3170303
Are you updating I
(check all that apply): If so, please provide the updated information:
❑ Project name
❑ Corporation Name'
® Permit Contact Name2,3 Ramsey Allen
® Permit Contact Title Member
El Mailing Address3 .
❑ Phone number
❑ Email address
1 Provide documentation such as a Name Change/Merger filed with the NCSOS.
2 Provide supporting documentation such as NCSOS filing. The permit contact's position must be in accordance
with 15A NCAC 02H .1040(1).
s If more than one point of contact or mailing address is being changed. please attach a separate sheet.
f3. CERTIFICATION OF PERMITTEE
I, Ramsey Allen , the current permittee, hereby notify DEMLR that I am making the changes as listed
in Section A above. I further attest that this application for an update to the permit information currently on file is accurate
and complete to the best(off nowledge. (� )
Signature: y Date: '" _" '
I, grt � IV)r /(n.- e/ , a Notary Public for the State of j (1. (1 re 1,na ,
County of C4`.' •1/ , do hereby certify that .c v Sr...y v.\11t0
personally appeared before me this the 11 day of Iv n.e. , 20 21, and acknowledge the due
execution of the forgoing instrument. Witness my hand and official seal,
(Notary Seal)
Notary Signature '�1- h,A BRENT MILLER
NOTARY PUBLIC
My commission expires 6S 120I2o2e $TONANL C IRNTY NC
�MY COMMISSION EXPIRES MARCH 20,2028
Stormwater Permit Information Update Form Page 1 of 1 May 11, 2017