North Carolina > Statewide > Division Of Water Quality > Surface Water Protection Section
Permit Name Ownership Change Form - North Carolina
| Permit Name Ownership Change Form Form. This is a North Carolina form and can be used in Surface Water Protection Section Division Of Water Quality Statewide . |
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Beverly Eaves Perdue, Governor Dee Freeman, Secretary North Carolina Department of Environment and Natural Resources Coleen H. Sullins, Director Division of Water Quality SURFACE WATER PROTECTION SECTION PERMIT NAME/OWNERSHIP CHANGE FORM I. Please enter the permit number for which the change is requested. NPDES Permit (or) Certificate of Coverage NC00 NCG5 Permit status prior to status change. a. Permit issued to (company name): b. Person legally responsible for permit: First MI Title Permit Holder Mailing Address City State Zip Last II. ( c. Facility name (discharge): d. Facility address: ) Phone ( ) Fax Address City State Zip III. ( ) Phone First / MI / Last Please provide the following for the requested change (revised permit). a. Request for change is a result of: Change in ownership of the facility 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 Title Permit Holder Mailing Address City State E-mail Address Zip Last e. Facility contact person: ( d. Facility name (discharge): e. Facility address: ) Phone Address City State MI E-mail Address American LegalNet, Inc. www.FormsWorkFlow.com Zip Last f. Facility contact person: First ( Revised 1/2009 ) Phone 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 Title Mailing Address City State E-mail Address Zip Last ( V. ) Phone 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 1/2009 American LegalNet, Inc. www.FormsWorkFlow.com
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