NCG550019_Owner Name Change_20180831

r•\ ROY COOPER
Governor
R .x"•I !
MICHAEL S. REGAN
t• a { Secretary
LINDA CULPEPPER
Water Resources Interim Director
ENVIRONMENTAL QUALITY
NPDES Certificate of Coverage (CoC)"_77
NCGS50.000 OWNERSHIP CHANGE FORM
I. Please enter the CoC number for which the change is requested.
Certificate of Coverage
• C G $/ 5 0 0 [
II. Please provide the following for the requested change(revised permit).
a. Request for change is a result of: Change in ownership of the residence/property
❑ Name change of the facility or owner
If other please explain:
b. Permit will be issued to (company
name, if applicable):
c. Person legally responsible for permit:
First MI Last
Title
Permit Holder Mailing Address
City State Zip
( )
Phone E-mail Address
d. Facility name(discharge): / Sty 044 4,4t-3f I2ivJ
e. Facility address: /31&/ c742,/1' ,c't Z2 i v t=
Address
l lls6c)rouc,l,‘ NC- Z24.4E3 ' 919/
City State Zip
f. Facility contact person:
[if different from Owner] First MI Last
( )
Phone E-mail Address
III. Permit contact information (if different from the person legally responsible for the permit)
Permit contact:
First MI Last
Title
Mailing Address
City State Zip
( )
Phone E-mail Address
Will this perm itted facility continue to discharge the same volume and type of wastewater as
prior to this ownership or name change?
❑ Yes
❑ No (please explain)
Revised 11/2017

NCG550000 OWNERSHIP CHANGE FORM
Page 2 of 2
VI. Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED BFITEMS
ARE INCOMPLETE OR MISSING:
❑ This completed application is required for both name change and/or ownership change
requests.
❑ Legal documentation of the transfer of ownership(such as a property deed, relevant pages of a
contract, or a bill of sale) is required for an ownership change request.
The certifications below must-be completed and signed-liy the new applicant in-the case of an ownership
change request.
APPLICANT CERTIFICATION
I, , 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 is not included,this application package will be
returned as incomplete.
Signature Date
PLEASE SEND THE COMPLETE APPLICATION PACKAGE TO:
NC DEQ/DWR/NPDES
1617 Mail Service Center
Raleigh,NC 27699-1617
Revised 11/2017