NC0020354_Owner Name Change_20031229

�0F W A%9 Michael F. Easley
Governor
�O G William G. Ross Jr., Secretary
Uj North Carolina Department of Environment and Natural Resources
Alan W. Klimek, P.E., Director
Q `C Division of Water Quality
WATER QUALITY SECTION
PERMIT NAME/OWNERSHIP CHANGE FORM
I.
H.
CURRENT PERMIT INFORMATION:
Permit Number: N/C/0 /O / %3/ ©/3/S/ 16 or
Certificate of Coverage Number: N/C/G/ /_ I -,_11
1. Permit holder's name: ID A -U 1 22J t ku G►
2. Permit's signing official's name and title: _bAy i t�,- (b. Ht)(A A t -S
(Person legally responsible for permit)
t oc�rJ MM &CM=4 --
(Title)
3. Mailing address: tom. a • �O X SC1 City:
State: Lf C� Zip Code: a 1 � 1 2 --
NEW OWNER/NAME INFORMATION:
1. This request for change is a result of.
❑ Change in ownership of company
❑ Change in ownership of property/facility
Phone: (q (9) '54 %' y (-a
❑ Name change for company
❑ Name change for property/facility
Lg'Other (please explain): G "woy JkC CAF 3 t 1A a r ,,Jk 01=C=, C t A (_
2. Owner/Operator Information
Company or Owner or Operator Name: ti7F Qr TTSI:JC)�t0
(name to be put on permit / certificate of coverage)
Owner's/operator's or signing official's name: -amu t 1J (3. t'tWOTitle: r-AAaAC4CL--
Owner Contact: -T-)AQ1(> (!:)• (-)Ct)is+KES Title:-t-OX—')J MtArJAAEw-
Mailing address: t7 . ('3 O %4 -1 S'�i City: __P t TT _-) ('J O jL0
State: mt C-1 Zip Code: eQ 13 t 2--' Phone: (-{ tg) 1541- y (a A I
E-mail address: tom- " tJ i,-, 6t E 5 (sy i'.3 C_ . P—(2-. C)Ct'M
3. Facility Information
Facility Name: -_�:>' -r-v:> ('S C. 20 WA—re G -5A -r eAL- R_,Eo*TM EV�J T 'P I A,,�
Facility Contact: t�—Z.[2 Y Title: F� S S i O2.C.•
Facility Mailing address:P. O i:L-) O X _7'591 City:
State: L%,�A C– Zip Code: 01-1 3 t Z Phone: ( q t 9)
E-mail address: 1P Dom 2(9? C K iLA T'Ec44 —Got -1
SW U-239-080102

PERMIT NAME / OWNERSHIP CHANGE FORM
4. Permit Contact Information (if different from facility contact)
Permit Contact:
Mailing address
State: Zip Code:
E-mail address:
Title:
City:
Phone: ( )
THIS APPLICATION PACKAGE WILL NOT BE ACCEPTED BY THE DIVISION OF WATER QUALITY UNLESS
ALL OF THE APPLICABLE ITEMS LISTED BELOW ARE INCLUDED WITH THE SUBMITTAL.
REQUIRED ITEMS:
1. This completed application
2. Legal documentation of the transfer of ownership (such as a contract, deed, articles of incorporation)
Certification must be completed and signed by both the current permit holder and the new applicant in the case of change of
ownership. For name change only, complete and sign the application certification.
Current Permittee's Certification:
I, 7A V l n ('s. VU G► x+05 , attest that this application for 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:
Applicant's Certification:
I, ►.1, V E5 , 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: �t 306±t Date:
THE COMPLETED APPLICATION PACKAGE, INCLUDING ALL SUPPORTING INFORMATION & MATERIALS,
SHOULD BE SENT TO THE FOLLOWING ADDDRESS:
Point Source Branch
Attn: Valery Stephens
Division of Water Quality
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
SWU-239-080102

REM By i tdlT)'1,
DEC 31 03