NCG550227_Owner Name Change_20181210

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NORTH CAROLINA
Environmental Quality
NPDES Certificate of Coverage(CoC)
NCG550000 OWNERSHIP CHANGE FORM
I. Please enter the CoC number for which the change is requested.
Certificate of Coverage
I I I I N C G 5 5I - 27
II. Please provide the following for the requested change-(revised CoC).
a.Request for change is a result of: ,�'Eltange in ownership of the residence/property
Name change of the facility or owner
If other please explain: I
b. CoC will be issued to(person's name or �
company name,if applicable): ta� M . p
C. Owner:person legally responsible for x, �����0 DEC 10 2018
CoC: .� $
First MI Last
Water Resources
f�nti2S V�R Permitting Section
Title
Permit Holder Mailing Address
.r3 Fo2'LoRIB(' C
City State Zip
o ithM:1 et251YWrftl1e. MC, Z9741
Phone E-mail Address
d. Facility name(if applicable): g2$ t/'$'7 7L//t 4.01NAC be115 o?tder
e.Facility address:
Address
City State Zip
f.Facility contact person:
[if different from Owner] First MI Last
0
Phone E-mail Address
III,Contact person(if different from the person legally responsible for the CoC)
First MI Last
Title
,
Mailing Address
City State Zip
0
Phone E-mail Address
IV Will this permitted facility continue to discharge the same volume and type of wastewater as
prior to this ownership or name change?
X Yes
No(please explain)

4 !„
Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS
V. 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 by 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.
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PLEASE SEND THE C q�I'LETE APPLICATION PACKAGE TO:
der
NC DEQ/DWR/NPDES
1617 Mail Service Center
Raleigh,NC 27699-1617
Revised 12/2018