NC0043176_Owner Affiliation Change_20180706

ROY COOPER
Governor
N
'' MICHAEL S. REGAN
- - .s<cretaw y,
- LINDA CULPEPPER
Water Resources lnlermi T)irechn
ENVIRONMENTAL QUALITY
PERMIT NAME/OWNERSHIP CHANGE FORM .
I. CURRENT PERMIT INFORMATION:
Permit Number: NCOO 4 / 3 / 1 / 7 / 6 or NCG5 / / / /
1 Facility Name City of Dunn
H. NEW-OWNER/NAME INFORMATION: RECEIVED/DENR/DWR
-
1. This°request for a name change is a result of: JUL 0 6 2018
x a. Change in ownership of property/company Water Resources
Permitting Section
b. Name change only
c. Other(please explain):
2. New owner's name (name to be put on permit).
Steven Neuschafer ,
3 New owner's or signing official's name and title: Steven Neuschafer
(Person legally responsible for permit)
City Manager
(Title)
4. Mailing address: PO Box 1065 City: Dunn
State- NC Zip Code- 28335 Phone ( 910 ) 230-3500
sneuschafer@dunn—nc.org
E-mail address
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
haps://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:
Steven Neuschafer , 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 i►formation and attachments are not included,°this application
package will be re 7.rn:•� incomplete.
Signature: Date:ZJ Zot
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