NCG500648_Owner (Name Change)_20190624

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June 24, 2019
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Andrew Pitner, Assistant Regional Supervisor
North Carolina Department of Environmental Quality
Mooresville Regional Office
610 East Center Avenue, Suite 301
Mooresville, NC 2811
JUL 11 201
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Re: Name Change Request for "Carolinas Medical Center — Mercy" to "Atrium Health Mercy, a facility
of Carolinas Medical Center"
General Wastewater Discharge Permit NCG500000, Certificate NCG500648, effective October 13, 2015
Dear Sir:
The purpose of this letter is to request a name change for The Charlotte -Mecklenburg Hospital Authority
d/b/a Carolinas Medical Center — Mercy.
Currently, the name is as follows: Carolinas Medical Center - Mercy [The Charlotte -Mecklenburg
Hospital Authority d/b/a Carolinas Medical Center — Mercy]
Effective August 1, 2019, the "doing business as" name of the Hospital is changing. Accordingly, please
update your records to reflect the new name of the Hospital as follows:
Name: Atrium Health Mercy, a facility of Carolinas Medical Center [The Charlotte -Mecklenburg
Hospital Authority d/b/a Atrium Health Mercy]
Please note that this is simply a d/b/a name change -- there will be no change in ownership, control,
address, personnel, officers, or any other operations of the Hospital as a result of this d/b/a name change,
and the Hospital will continue to be an operating division of The Charlotte -Mecklenburg Hospital
Authority.
Please do not hesitate to contact me at 704-681-1177 or [e-mail] if you have any
questions or need additional information regarding this d/b/a name change.
Sincerely,
Hal Zablocki
Manager/Service Leader
2015-01962
91 7199 9991 7031 0756 6201

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ENVIRONMENTAL G2UAL11 Y
PAT MCCRORY
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DONALD R. VAN DER VAART
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S. J ZIMMERMAN
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Permit Number: NCG5000000 Certificate NCG500648
1. Facility Name: Carolinas Medical Center - Mercy
II. NEW OWNER/NAME INFORMATION:
1. This request for a name change is a result of:
a. Change in ownership of property/company
_X b. Name change only
c. Other (please explain):
2. New owner's name (name to be put on permit):
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Atrium Health Mercy, a facility of Carolinas Medical Center
3. New owner's or signing official's name and title: /94l C,/� z4a ek
(Person legally responsible for permit)
Manager/Service Leader
(Title)
4. Mailing address: 2001 Vail Avenue City: Charlotte
State: NC Zip Code: 28207 Phone: [phone]
E-mail address: Hal.Zablockieatriumhealth. org
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,ne. govlaboutldivisions/water-resources/water-resources-permits/wastewater-branchlnpdes-wastewater-permits

NPDES Name & Ownership Change
Page 2 of 2
Applicant's Certification:
, Al -0/, za �/Ie-k), , 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 and attachments are not included, this application
package will be returned as incomplete.
Signature: Date:
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NC DEQ / DWR / NPDES
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Version 712016