NCG110047_Owner Name Change Review Form_4/9/2018

Environmental
Quakry
I. Permit Information
I. Please enter the permit number for which the change is requested.
NPDES Stormwater Individual Permit #:
NC
SX
XX
XX
X
-OR-
General Permit Certificate of Coverage (COC) #:
NCG110047
Use this link to check the permit contact information that is currently in our database.

II. Permit Status
11. Permit status prior to requested change.
a. Permit issued to: Town of Apex
Company Nlarre
b. Person legally responsible for permit:
First name: Middle name: Last name:
Drew Havens
Title: Town Manager
Permit holder's mailing address:
Phone #:
91924
93301
c. Facility name:
d. Facility address:
Fax #:
91924
93305
Street Address
P.O. Box 250
Address Line 2
City
State / Province / Fbgion
Apex
NC
Fbstal / Zip Code
Country
27502
us
Apex Water Reclamation Facility
Street Address
300 Pristine Water Drive
Address Line 2
oty
State / Province / Fbgion
Apex
NC
Fbstal / Zip Code
Country
27539
us
e. Facility contact person (prior to change, optional):
First name: Middle name: Last name:
Phone #:

III. Requested Change Information
111. Please provide the following for the requested change (revised permit).
a. Request for changes is a result of: r Change in ownership of facility
r Name Change of the facility or owner
b. Permit to be issued to: Town of Apex
Company Nlarre
c. Person to be legally responsible for permit:
First name: Middle name:
Last name:
300 Pristine Water Drive
Drew
Havens
Title:
Town Manager
Apex
Permit holder's mailing address:
Street Address
Country
27539
P.O. Box 250
Address Line 2
oty
State / Province / Fbgion
Apex
NC
Fbstal / Zip Code
Country
27502
us
Phone #
91924
93301
d. Faciltiy name:
e. Facility address:
Email address:
d rew. hav
ens@ap
exnc.org
Apex Water Reclamation Facility
Street Address
300 Pristine Water Drive
Address Line 2
oty
State / Province / Fbgion
Apex
NC
Fbstal / Zip Code
Country
27539
us
Is the FACILITY contact different than the person legally responsible
above?
r Yes
r No
f. Facility contact person:
First name
John
Phone #:
Middle name
9192493366
Email address: [e-mail]
Last name:
Cratch

IV. Permit Contact Information
Is the PERMIT contact different than the person legally responsible
above?
r Yes
r No
IV. Permit contact information
(if different formthe person legallyresponsible for the
.................................................................................................................................
First Name: Middle
John Name:
Title:
Mailing Address:
Phone #
9192493360
Last Name:
Cratch
Apex WRF Manager
Street Address
P.O Box 250
Address Line 2
City
Apex
F bstal / Zip Code
27502
Email Address: [e-mail]
State / Rovince / Fbgion
NC
Country
US

V. Permit Facility Activities
V. Will the permitted facility continue to conduct the SAME industrial activities conducted prior to this
ownership or name change:
r Yes
r No

VI. Signature
In the case of an ownership change request, signed certifications must be completed by both the
permit holder prior to the change and the new applicant. For a name change request, the signed
Permittee's Certification is sufficient.
This completed application is required for both name change and/or ownership change requests.
Legal documentation of transfer of ownership (such as relevant pages of a contract deed, or a bill of
sale) is required for an ownership change request. Articles of incorporation are not sufficient for an
ownership change.
File Upload: Upload supporting docurrentation for ownership change
NCG110047 Contacts.pdf 163.38KB
pdf only
Signed Certification Upload A signed certif ication staterrent is required
NCG110047 Contacts.pdf 163.38KB
pdf only

Initial Review
Project ID:* NCG110047