WQ0041126_Owner (Name Change)_20191210

State of North Carolina
Department of Environmental Quality
Division of Water Resources
PMLR SEWER SYSTEM PERMIT OWNERSHIP/NAME CHANGE
'DMslon of Water Resources INSTRUCTIONS FOR FORM: PNOCF 01-16
1. EXISTING PERMITTEE INFORMATION
I. Permittee's name: Ci!y of Northwest
2. Signature authority's name: James Knox per 15A NCAC 02T .0106(b)
3. Signature authority's title: Mayor
4. Permittee's mailing address: 4889 Vernon Road
City: Northwest State: NC Zip: 28451
5. Permittee's contact information: Phone number: (2-WO) 655-3110 Fax Number (_)
Email Address: city0erkQi;itvofnorthwest.com
II. APPLICANT INFORMATION:
I. Applicant's name: Brunswick County Public Utilities
2. Signature authority's name: John Nichols per 13A NCAC 02T_,0106(bl
3. Signature authority's title: Director of Public Utilities
4. Applicant's mailing address: P.O. Box 249
City: Bolivia State: NC Zip: 28422
5. Applicant's contact information: Phone number: 910 25372653 Fax Number (910) 253-420
Email Address: John.nichols(abrunswickcountync.g4y
6. Representative's name: _
7. Representative's title:
8. Representative's contact information
III. PERMIT INFORMATION:
Phone number: (_)
Email Address:
Fax Number C-_)
I. Existing permit number: W00041 126 and most recent issuance date: October 14, 2019
2. Reason for the permit application: Change of Ownership If other, attach detailed explanation
3. Has the facility been constructed? ❑ Yes or ® No
4. Has the facility been certified per 15A NCAC 02T 01 16 0 Yes or ® No
FORM: PNOCF01-16 Page I oft

IV. CERTIFICATIONS:
Existing Permittee's Certification per I5A NCAC 02T .0106(b):
r" - t attest that this application
(Signature AIM 'ty's ame & title from Application Item 1.2 & 3)
has been reviewed by me and is accurate and complete to the best of my knowledge. 1 understand that prior to reissuance of the permit
into the Applicant's name, 1 will continue to be responsible for compliance with the current permit and any discharge of wastewater
from this system to surface waters or the land may result in an enforcement action that may include civil penalties, injunctive relief,
and/or criminal prosecution. I will also make no claim against the Division of Water Resources should a condition of the existing permit
be violated. I also understand that if all required parts of this application are note completed and that if all required supporting
information and attachments are not included, this application will be returned to me as incomplete.
NOTE — In accordance with General Statutes M-.MAA and 141-2j�JQ, any person who knowingly makes any false statement,
representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may include a fine not to
exceed $10,000 as well as civil penalties up to $25,000 per violation. nn.t
Signature: JAdM& , Ik�>0 Date: ✓ll I 19
1
Applicant's Certification per I5A NCAC 02T .0106(b):
1, _T John Nichols _attest that this application
(Signature Authority's name & title from Application Item 11.2&3.)
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that afler issuance of the permit into
the Applicant's name, I will be responsible for compliance with the issued permit and any discharge of wastewater from this non -
discharge system to surface waters or the land may result in an enforcement action that may include civil penalties, injunctive relief,
and/or criminal prosecution. I will make no claim against the Division of Water Resources should a condition of this permit be violated.
I also understand that if all required parts of this application package are not completed and that if all required supporting information
and attachments are not included, this application package will be returned to me as incomplete.
NOTE — In accordance with General Statutes W-2,I,LM and 143-215.6B, any person who knowingly makes any false statement,
representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may include a fine not to
exceed $10,000 as well as civil penaltup to $ 5, 0 p violation.
Signature: Date: 11 /27/2019
_....._..____.
FORM: PNOCF 0 1- 16 Page 2 of