NCS000558_FRO Form_20180130

V
PERMIT NAME/OWNERSHIP CHANGE FORM
CURRENT PERMIT INFORMATION:
Permit Number: NCS000558 or NCG5 / / / /
1 Facility Name: Town of Benson
II. NEW OWNER/NAME INFORMATION: RECEIVEUIDEMPOWR
1. This request for a name change is a result of: AN 3 0 2018
a. Change in ownership of property/company water Resources
Perr�m►fting
_X—b. Name change only
c. Other (please explain):
2. New owner's name (name to be put on permit):
Timothy W. Robbins
3. New owner's or signing official's name and title: Timothy W. Robbins
(Person legally responsible for permit)
Public Works Director
(Title)
4. Mailing address: PO Box 69 City: Benson
State: NC Zip Code. 27504 Phone: [phone]
E-mail address: trobbinsCaDtownofbenson.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/aboutldivisions/water-resources/water-resources-permits/wastewater-branchlnpdes-wastewater-permits

NPDES Name & Ownership Change
Page 2 of 2
Applicant's Certification:
I, Timothy W Robbins , 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.
Signature: Date: o 7-5 z -v I d
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 7/2016