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Permit Name Ownership Change Form. This is a North Carolina form and can be use in Division Of Water Quality Statewide.
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Tags: Permit Name Ownership Change Form, North Carolina Statewide, Division Of Water Quality
Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Alan W. Klimek, P.E. 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
N C
II.
N C G
Permit status prior to status 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).
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 /
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
(
Phone
Revised 7/2005
/
MI
/
Last
)
E-mail Address
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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
(
Zip
)
Phone
V.
State
E-mail Address
Will the permitted facility continue to conduct the same industrial activities conducted prior to
this ownership or name change?
! Yes
! No (please explain)
VI.
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):
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 is not included, this
application package will be returned as incomplete.
Signature
Date
APPLICANT CERTIFICATION:
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 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 7/2005
American LegalNet, Inc.
www.FormsWorkflow.com
