NCG020863_Name Ownership Change Request Form 3_20190604

New Submission
Page 1 of 2
ea' %TAT[..
NPDES Permit Name/Ownership Change
n
NOrtTHCAROUNA Request
Env MFiMdrnfol QU011Iy
I. Permit Information 1 II. Permit Status 1 III. Requested Change Information
IV. Permit Contact Information I V. Permit Facility Activities I VI. Signature
Is the PERMIT contact different than the person legally responsible above?*
QQ Yes
Q No
IV. Permit contact information
(if different form the person legally responsible for the permit)
First Name: * Middle Name: Last Name:
Tony Johnson
Title:
Environmental Engineer
Mailing Address: * Street Address
11020 David Taylor Drive
Address Line 2
City State / Province / Region
Charlotte NC
Postal / Zip Code Country
28262 US
Phone #: * 704-547-7076
Email Address: * [e-mail]
Previous
Next
https://edocs.deq.nc.gov/Forms/SW-Name-Change 6/4/2019

New Submission Page 2 of 2
Save as Draft
https://edocs.deq.nc.gov/Forms/SW-Name-Change 6/4/2019