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Home My WebLink AboutNCG070176_Name Ownership Change_20180425NPDES Permit Name/Ownership Change Request I. Permit Information II. Pennit Status III. Requested Change Information �rii'IfOA7nC711li( L}tiality IV. Permit Contact information V. Permit Facility Activities Vi. Signature I. Please enter the permit number for which the change is requested. NPDES Stormwater Individual Permit #. -OR- General Permit Certificate of Coverage (COC) #: J 70 NCGXXXXXX Use this link to check the permit contact information (hftps:#reports.nodenr.org/BOE/OpenDocument/l 703191515/Crys id=25212&apsuser-BIMS U&apspassword=b10Ms cr0/o28ddnri5E that is currently in our database. R'a:i_US Next Save as Draft REC�� APR 2 5 X018 DIaNWND QUALI`i`t ST®RMWATER PERMITTING K, n. M W�- NPDES Permit Name/Ownership it status Ill. Requested Change Information I IV. Permit Contact Information V. Permit Facility Activities I VI. Signature 11. Permit status prior to requested change. ........................... Un tkef- 14 E r .......... a. Permit issued to:* 1 9/19 14t, ldf,- f1l AIJe -QF r'1NC- -C, Company Name b. Person legally responsible for permit: First name:* Middle name: Last name:* I -&, I - -- I 1Yj1j9tTk-1T7dF-r- Title: Permit holder's mailing address: * Phone #: * Fax #: Pr -,F J, I'd F -Al Street Address jEnter a location 14t7l Rd - Address Line 2 city State / Province / Region I eAr-th nq L F—.tvc- Postal / Zip Code Country c. Facility name:* I f- Id E t- 'Jfi-IV r V i'e- F �e Environmental Quohity NPDES Permit Name/Ownership 111111. Requested Change Information V. Permit Facility Activities I VI. Signature IV. Permit Contact Information 111. Please provide the following for the requested change (revised permit). . ...... .... . .... . ............. ........ . . .... ................. -- .......... ...... ... ............... ... ............. ...... ...... .............. .......... a. Request for changes is a a Change in ownership of facility result of: * 0 Name Change of the facility or owner b. Permit to be issued to: e -r i IOWA- :Z� Company Name c. Person to be legally responsible for permit: First name: Middle name: Last name: Title: Permit holder's mailing Street Address address: lEnter a location Address Line 2 City State / Province / Region I Gay- hnqF- F—W-- Postal / Zip Code Country Phone #: * Email Iq Iq --jjf rig I address: EA14-9 q OVWErs SE.p�'C-fftd En v;runmen?cal NPDES Permit Name/Ownership ;ft"OefteoUeStStatus 1 III. Requested Change Information IV. Permit Contact Information V. Permit Facility Activities VI. Signature V. Will the permitted facility continue to conduct the SAME industrial activities conducted prior to this ownership or name change: Yes Q No Previous Next Save as Draft d. Faciltiy name:* e. Facility address:* Street Address Enter a location 42/ Address Line 2 City State / Province / Region r- h Postal / Zip Code Country Is the FACILITY contact different than the person legally responsible above?* ® Yes No Previous Save as Draft Next d. Facility address:* Street address Enter a location 1,,'Z-1 _j�} c).ji 1//"1l Address Line 2 City State / Province / Region qtr Postal / Zip Code rCountry e. Facility contact person (prior to change, optional): First name: Middle name: Last name: Phone #: Previous Save as Draft Next Permit Name/Ownership Change Why is this signed form needed? Permittees and/or applicants must fulfill signatory requirements in the NPDES federal regulations in 40 CFR §122.22. Until electronic submittal meets Cross -Media Electronic Reporting (CROMERR) requirements, this signed form must either be submitted with the application or mailed separately to: DEMLR Stormwater Program 1612 Mail- Service Center 512 North Salisbury Street Raleigh, NC 27699-1612 12"' CHECK HERE IF APPLICANT WILL MAIL IN SIGNED FORM INSTEAD. Permit Number j✓C er. 0 7 d North Carolina General Statute 143-215.6 b (i) provides that: Any person who knowingly makes any false statement, representation, or certification in any application, record, report, plan, or other document filed or required to be maintained under this Article or a rule implementing this Article; or who knowingly makes a false statement of a material fact in a rulemaking proceeding or contested case under this Article; or who falsifies, tampers with, or knowingly renders inaccurate any recording or monitoring device or method required to be operated or maintained under this Article or rules of the [Environmental Management] Commission implementing this Article shall be guilty of a Class 2 misdemeanor which may include a fine not to exceed ten thousand dollars ($10,000). Applicant Certification (To whom permit is to be transferred) I, L Ula) r(Y(1 Qfl Y rlQ V, attest that this application for a name or 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 is not included, this application package will be returned as incomplete. PQ^J&, 1 18 Signature ate BOOK4889 - PAGE314 For Registration Register of Deeds Judy D. Martin Moore County, NC Electronically Recorded October 20, 2017 3:26:39 PM Book: 4889 . Page: 314 - 317 #Pages: 4 Fee: $26.00 NC Rev Stamp: 61,000.00 instrument# 2017015471 GF,NERAL WARRANTY DEED REVENUE: $ 1 Oo o.0 - MAIL MAIL AFTER RECORDING TO: \NNI Fs 1269=% iAc. A41—rftv-rl "'4e - THIS INSTRUMENT WAS PREPARED BY: Robert G. Collins Grantor's primary residence: NO STATE OF NORTH CAROLINA COUNTY OF MOORE WITHOUT TITLE EXAMINATION PARCEL: 10002291 THIS DEED made this. / day of `'�_j,, 2017, by and between Timothy H. Blackwelder and wife Tamara Blackwelder, Tamara Blackwelder signing for purposes of conveying her marital interest only, hereinafter called GRANTORS, and Garners - Septic Tanks, Inc., a NC corporationyvhose mailing address is $ -rLJ ^k„� 2� -7 C , heminafter called GRANTER: The designation of Grantor and Grantee as used herein shall include said parties, their heirs, successors and assigns, and shall include singular, plural, masculine, feminine or neuter as required by context. WITNESSETH That the Grantor, for a valuable consideration Maid by the Grantee, the receipt of which is hereby acknowledged, has and by these presents does grant, bargain, Belt and convey unto the Grantee in fee sitnple, all that certain lot or parcel of land situated in MOORE County, North Carolina and more particularly described as follows: SEE ATTACHED EXHIBIT "A" submitted electronically by "Clarke, Phifer, Vaughn, Brenner & McNeill, PLLc" in compliance with North Carolina statutes governing recordable documents and the terms of the submitter agreement with the Moore county Register of Deeds. Permit Name/Ownership Change PERMITTEE Certit cation Signature Supplement Fi' Why is this signed form needed? Permittees and/or applicants must fulfill signatory requirements in the NPDES federal regulations in 40 CFR §122.22. Until electronic submittal meets Cross -Media Electronic Reporting (CRCIMERR) requirements, this signed form must either be submitted with the application or mailed separately to: DEMLR Stormwater Program / 1612 Mail Service Center ✓ 512 North Salisbury Street Raleigh, NC 27699-1612 5l CHECK HERE IF PERMITTEE WILL MAIL IN SIGNED FORM INSTEAD. Permit Number dG d 0 76 VI � North Carolina General Statute 143-215.6 b (i) provides that: Any person who knowingly makes any false statement, representation, or certification in any application, record, report, plan, or other document filed or required to be maintained under this Article or a rule implementing this Article; or who knowingly makes a false statement of a material fact in a rulemaking proceeding or contested case under this Article; or who falsifies, tampers with, or knowingly renders inaccurate any recording or monitoring device or method required to be operated or maintained under this Article or rules of the [Environmental Management] Commission implementing this Article shall be guilty of a Class 2 misdemeanor which may include a fine not to exceed ten thousand dollars ($10,000). Permittee Certification (Permit holder prior to the ownership change or permit holder authorizing name chari!ge) attest that this application for a name or 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 is not included, this application package will be returned as incomplete. .Jure.-ti[�,O±a�. V I q Ap Signature Date WILLCOX, MCFADYEN, FIELDS & SUTHERLAND PLLC ATTORNEYS AT LAW 112 E. EDINBOROUGH AVENUE RAEFORD, NORTH CAROLINA 28376 R. PALMER WILLCOX, (1935 — 2008) DUNCAN B. McFADYEN, 111 (1948 — 2012) WILLIAM C. FIELDS, JR. REGINA ROBERTS SUTHERLAND CANDACE E. HAYWORTH March 22, 2018 Edward Garner 8434 Turnpike Rd. Raeford, NC 28376 RE: Deed for 10.31 acres, Moore County Dear Mr. Garner: POST OFFICE BOX 126 PHONE 910.875.4065 FAX 910.875.6710 E-mail: fields@mefordlawyer.com Enclosed please find the original Deed for the property described above, which has been duly recorded in the Moore County Public Registry. I have included a copy of the page showing the recordation since this deed was recorded electronically. Please make sure you hazard insurance carrier is aware of this transaction. The title insurance company will send the title policy directly to you. Please do not hesitate to contact me if you have any questions or concerns. Thank you for allowing our firm to be of assistance to you in this matter. Si cerel i WilliamVFields, WCF:eam Enclosure