NCG590016_Owner (Affiliation Change)_20190709

ROY COOPER
Governor
N
-Y
MICHAEL S. REGAN
Secretary
LINDA CULPEPPER
Water Resources Interim Director
ENVIRONMENTAL QUALITY
PERMIT NAME/OWNERSHIP CHANGE FORM
I. CURRENT PERMIT INFORMATION:
Permit Number: NCO() /�1 -//� / /� / or NCG5 q/D/DIIIJ
1. FacilityName: O to N O T /V `Ce-d SON W TP
i2ECEIVED/NODE@/DWR
II. NEW OWNER/NAME INFORMATION: AUG 2 6 2019
1. This request for a name change is a result of:
Water Quality
a. Change in ownership of property/company Permitting Section
b. Name change only r /rh�
✓c. Other(please explain): CrIGW0Q ;Ai re.S/3ONSt t le. o� c%a..( ON ki
2. New owners name(name to be put on permit):
3. New owner's or signing official's name and title: ` epI/U a-c[ �1n.1
(Person legally r�onsible for permit)
/vwN etA/ex e-r'
/, J (Title)tl U
4. Mailing address: /g 0 At. /►4O(4 ce7 City: /�[acr.'/��SC—A`
State: .'- Zip Code. c 70.2-( Phone: ( 3349) 1.0 7 - 3 q 7 /
E-mail address: rha-ar/WQ7LtJzt.d i�ct.G(; L. Ocsn
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 ofNorth 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.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: /
I, l'«U2� 1',(4 0 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 and attachments are not included, this application
package will be returned as incomplete.
Signature: Date: 5- 2 ."- 9
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

July 9,2019
Wastewater Branch
Water Quality Permitting Section
Division of Water Resources
1617 Mail Service Center
Raleigh,NC 27699-1617
Subject: Delegation of Signature Authority "�
ENTER FACILITY NAME Tc wv` a /'I-P &O1:soN ( ‘ P
NPDES Permit Number NC CC--t SS q oO 1 (p
To Whom It May Concern:
By notice of this letter, I hereby delegate signatory authority to each of the following individuals for all
permit applications, discharge monitoring reports, and other information relating to the operations at
the subject facility as required by all applicable federal, state, and local environmental agencies
specifically with the requirements for signatory authority as specified in 15A NCAC 2B.0506.
Individual #1 Individual#2 (if applicable)
Name: . " � reji i bi9-'�f S
'Title:
(A �� N�r;wiepki e Art-
,
Mailing"Address:,' � A
�rm:sat.%3
Physical Address: ' Lib3 Li,.1dlse4 13r;ci a .
(if different) Mad:s 6 o1-7UAS
Email Address:�w �ak tm,w-l40 owN c1 /vl0.�YsoN
Office Phone: n ?(e - - 397 ( - -
Mobile°Phone: , °334, -Ss30- aqg(, - -
If you have any questions regarding this letter, please feel free to contact me at Enter Email or Phone
Number.
Sincerely,
Authorized Signing Official's Name KU'l I h
Authorized Signing Official's Title --rowa� ath
Mailing Address 12, ,Aar-fa- cL/ A(A_LL soi,AK_
Email Address Kbeeu�jhivot �d_ 4 .,rcj
Office Phone 33(0.t2-1 OZZ1
Mobile Phone336.00-0; 1(
cc: Select a region Regional Office, Water Quality Permitting Section