NC0026441_Owner (Affiliation Change)_20240806

NORTH CAROLINA
Environmental Quality
NC DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF WATER RESOURCES
WATER QUALITY PERMITTING SECTION
NPDES PERMITTING
xPERMIT NAME OWNERSHIP CHANGE FORM
CURRENT PERMIT INFORMATION:
Permit Number: NC00_2_/_6J_4_/_4_/1 or NCG5_j—/—/_/_
1. Facility Name: Town of .Siler Cit
NEW OWNERMAME INFORMATION:
1. This request for a name change is a result of:
_X_a. Change in ownership of property/company
b. Name change only
c. Other (please explain):
2, New owner's name (name to be put on permit):
Jack Meadows
3. New owner's or signing official's name and title: Jack Meadows
(Person legally responsible for permit)
Interim Acting Town Manager
(Title)
4. Mailing address: PO Box 769
State: NC_ Zip Code: 27344
E-mail address: [e-mail].
FACILITY AND DISCHARGE INFORMATION
City: Siler City
Phone: [phone]
1. Will the waste stream for the facility remain the same as under the previous owner? Yes X No ❑
2. Will the treatment system and discharge location remain the same? Yes X No ❑
"No Responses"
if either or both of these questions are answered `No" then more information will be needed to review the
request. Please attach documentation to describe and explain the changes to the facility activities, waste
D ��� North Carolina Department of Environmental Quality I Division of Water Quality
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512 North Salisbury Street 1 1617 Mail Service Center I Raleigh, North Carolina 27699-1617
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NPDES Name and Ownership Change
Page 2 of 2
stream, treatment process or outfoll location. The Division may not be able to process the Permit
Name/Ownership Change request and may require that the new owner file a new permit application.
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:
This completed application form
Legal documentation of the transfer of ownership (such as a property deed, articles of
incorporation, or sales agreement)
Information to document facility, waste stream, treatment system or outfall changes as noted in
item III above (if appropriate)
Applicant's Certification:
I, Jack Meadows , 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. I understand
that Permit Name/Ownership Change can only take place through action taken bV the Division of Water
Resources and that no actions on my part or the part of my company result in the automatic transfer of
permit coverage.
Signature: Date: �� r
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 07/2021