Permit Name Ownership Change Form

Division of Water Quality / Surface Water Protection National Pollutant Discharge Elimination System PERMIT NAME/OWNERSHIP CHANGE FORM I. FOR AGENCY USE ONLY Date Received Year Month Day II. Please enter the permit number for which the change is requested. NPDES Permit (or) Certificate of Coverage NCG NCS0 Permit status prior to requested change. a. Permit issued to (company name): b. Person legally responsible for permit: First MI Last Title Permit Holder Mailing Address City State Zip ( ) Phone ( ) Fax c. Facility name (discharge): d. Facility address: Address City State Zip e. Facility contact person: First / MI / Last ( ) Phone III. Please provide the following for the requested change (revised permit). Change in ownership of the facility a. Request for change is a result of: Name change of the facility or owner If other please explain: b. Permit issued to (company name): 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): e. Facility address: Address City State Zip f. Facility contact person: First MI Last ( ) Phone E-mail Address American LegalNet, Inc. www.FormsWorkFlow.com Revised 2012Apr23 NPDES PERMIT NAME/OWNERSHIP CHANGE FORM Page 2 of 2 IV. 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 V. VI. Will the permitted facility continue to conduct the same industrial activities conducted prior to this ownership or name change? Yes No (please explain) Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS 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 relevant pages of a contract deed, or a bill of sale) is required for an ownership change request. Articles of incorporation are not sufficient for an ownership change. The certifications below must be completed and signed by both the permit holder prior to the change, and the new applicant in the case of an ownership change request. For a name change request, the signed Applicant's Certification is sufficient. PERMITTEE CERTIFICATION (Permit holder prior to ownership change): , attest that this application for a name/ownership change has been reviewed and is accurate and I, 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 APPLICANT CERTIFICATION , attest that this application for a name/ownership change has been reviewed and is accurate and I, 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: Division of Water Quality Surface Water Protection Section 1617 Mail Service Center Raleigh, North Carolina 27699-1617 Revised 7/2008 American LegalNet, Inc. www.FormsWorkFlow.com