NC0023086_Signature Authority_20160701

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PERMIT NAME/OWNERSHIP CHANGE FORM
I. CURRENT PERMIT INFORMATION:
Permit Number: NC002/3/0/8/6 or NCGS / / / /
1. Facility Name. Town of Fontana Dam WWTP
II. NEW OWNER/NAME INFORMATION:
1. This request for a name change is a result of.
a. Change in ownership of property/company
X b. Name change only
c Other (please explain).
2. New owner's name (name to be put on permit)
Town of Fontana Dam
3. New owner's or signing official's name and title Zelerie Rogers
(Person legally responsible for permit)
Town Administrator
(Title)
4. Mailing address. P O Box 128 City. Fontana Dam
State: N.C. Zip Code:28733 Phone: [phone]
E-mail address: zelerie.rogers(a)fontanavillage.com
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 Service Center I Raleigh, NC 27699-1617
919 807 6300 919-807-6389 FAX
https://deq.nc.gov/about/divisions/water-resources/water-resources-permits/wastewater-branch/npdes-wastewater-permits

NPDES Name & Ownership Change
Page 2 of 2
Applicant's Certification:
I,_ Zelerie Rogers _ , 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.
. 5- ^
Signature: ESC. Date: aal1)
THE COMPL TED 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 712016