NC0036935_Owner (Affiliation Change)_20240819

D rtr, IDoP5
ROY COOPER
MICHAEL S. REGAN
%: %' I ,
LINDA CULPEP PER
Water Resources
ENVIRONMENTAL QUALITY
PERMIT NAMEIOWNERSHIP CHANGE FORM
I. CURRENT PERMIT INFORMATION:
Permit Number: NCOOJ b or NC05
1. Faciilty Name: PN t NOLf,04a;A% /XKPS
II. 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
--k1c. Other (plane explain): N*w9a nv f�yeA E L k O
2. New owner's name (name to be put on permit):
3. New owners or signing official's name and title: 4 RKO W n)
( arson legally responsible for permit)
�ffS/DsJr
(Title)
4. Mailing address: ,*,,S Xwecity: i?enitJelir z2ri✓q-r
State: A) C Zip Code: 0, ! z Phone: (gge) Y39 -YP9Y
E-mail address: 01We ffinud 2 JpoR (F g n&% . <*Dm
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]
State of North Carolina I Environmental Quality I Water Resources
1617 Mail Sc vicc Cuntcr I Ralcigb, NC 27699-1617
919 807 6300 919-807-6389 FAX
htips:l/deq.ne.govIaboWdMsiona/water-mwu testwater-resources-pemtita/wastewa%r-brmchlnpdes-wmtewaterpetmits

NPDES Name & Ownei * Cheops
Page 2 of 2
Applicant's Certlflcatlon:
I, WR oa A Bro L00 , 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.
Signatu e'� Date: Sl i Iaz
THE COMPL tED APPLICATION PACKAGE, INCLUDING ALL SUPPORTING
INFORMATION & MATERIALS, SHOULD BE SENT TO THE FOLLOWING ADDDRESS:
NC DEQ I DWR / NPDES
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Version 1112017