NC0026921_Owner (Affiliation Change)_20240722

PERMIT NAME/OWNERSHIP CHANGE FORM
CURRENT PERMIT INFORMATION:
Permit Number: '��tNCC00 �/ &/ ! / �/I or NCG5_/_/_/_/_
1. Facility Name: %TIC KTO a WO?
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
J� c. Other (please explain):CH/4M-) i11 �Sf�CSY1 lt3L OCFI C1+4
2. New owner's name (name to be put on permit): ©�
l7. 0 L) S L)n D ELCA-�a7
3. New owner's or signing official's name and title: D��S rib��arsY�
(Person legally responsible for permit)
Title)
4. Mailing address: City: )�
State: Ci Zip Code: a8�3`�1 Phone: (OUb ) OS06 .3 3 ( 6
I'iik7liFS:C:
THIS APPLICATION PACKAGE WILL NOT BE ACCEPTED BY THE DIVISION UNLESS A'LL 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]
State of North Carolina I Environmental Quality I Water Resources
1617 Mail Service Center I Raleigh, NC 27699-1617
919 807 6300 919-807-6389 FAX
https;//d eq. ne. gov/about/d i v i sions/water-resources/ivater-resources-perm its/wastewater-branch/npdes-wastewater-permits

NPDES Name & Ownership Change
Page 2 of 2
Applicant's Certification:
t11attest 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: Y Jam, � � i� rx Date: /
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 1112017