NC0021326_Owner Affiliation Change_20180628

ROY COOPER
Gores nos
MICHAEL S. REGAN
Sec,erm).
LINDA CULPEPPER
Water Resources
Intel Dmecla
ENVIRONMENTAL QUALITY
PERMIT NAME/OWNERSHIP CHANGE FORM
I. CURRENT PERMIT INFORMATION:
Permit Number: NCO() 2 / I / 3 /2 /lp or NCG5 / / / /
1. Facility Name: Dot 5C0r1 WNW
II. NEW OWNER/NAME INFORMATION:
1 This request for a name change is a result oRECEIVE®/®ENR/®WR
f
a. Change in ownership of property/company JUN 2018
a onlyWater Resources
✓t b. Name change Permitting Section
c Other(please explain):
2 New owner's name (name to be put on permit):
LcA Llxa. {.4. Nett.?
3. New owner's or signing official's name and title: Let.L,Lt N. NQ Q_ly
(Person legally responsible for permit)
Tours (ctaggf
1-� (Title)
�
4. Mailing address: -pin.b. Golc 3Si City. DObsor1
State:N C Zip Code: 7:1011 Phone: ("6'611) ) .5610-2 9(02
E-mail address: I aux . ye L1A ® do v -lase. Cc m
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, I _( .ur0. 1-4- N LQ.k , attest that this application for a
name/ownership change hag 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: df9cw.iu II . 1'ld Date: L[f alaJa018
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 11/2017