SW7001029_Permit Info Update Application Form_20241015

DEMUR 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: SW7001029
Are you updating(check all that apply): If so, please provide the updated information:
®Project name Tuscarora Landfill
❑Corporation Name' _
®Permit Contact Name Bobby Darden
❑Permit Contact Title _
❑ Mailing Address' _
❑Phone number _
® Email address bdarden(o.crswma.com
Provide documentation such as a Name Change/Merger filed with the NCSOS.
' Provide supporting documentation such as NCSOS filing. The permit contact's position must be in accordance
with 15A NCAC 02H .10400).
3 if more than one point of contact or mailing address is being changed,please attach a separate sheet.
B. CERTIFICATION OF PERMITTEE
I, Bobby Darden , 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 of my knowledge.
Signature:� �� K" Date:
I, �� w//(«��•4 (AtQhcT�L a Notary Public for the State of
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`Ct�LP (LI — do hereby certify that Ad ll. ,/ 4)e/du--
t� /
����ap me this the ' day of 20 , and acknowledge the due
y iatrument. Witness my hand and official seal,
nary eat)
� S �BL�
My com ' sio Aires
Stormwater Permit Information Update Form Page 1 of 1 May 11, 2017