nc0026565_Correspondence_20201216

ROY COOPER
„ NC F^, 3rtment of 00,11n"
r` Environrn ntalQuality
Re-eived MICHAEL S. REOAN
r"e:i, 16 2020 LINDA CULPEPPER
Lpartm
Water Resources Winston-Salem
Dheckn
ENVIRONMENTAL QUALITY V�'�nStOn-Salem
Regional Office
PERMIT NAME/OWNERSHIP CHANGE FORM
I. CURRENT PERMIT INFORMATION:
Permit Number: ' NC00 /_�o/,�/ /_5 or NCG5_/ /_/_/_
1. Facility Name: / °J AI Qf' t-OP—, W10-r %
II. NEW OWNER/NAME INFORMATION:
1. This request for a name change is a result of:
a. Change in ownership of property/company
b. Name change only
_c. Other (please explain):
2. New owner's name (name to be put on permit):
%%/0 PIA, V f Q.0 c,OL e
3. New owner's or signing official's name and title: 96& &- W.A&
(Person legally responsible for permit)
(Title)
�^
4. Mailingaddress: %spa" �a�4 City: r4.1t-_ =LX
v State: C­' Zip Code: z73/P Phone:( 3346 1?9 `` S&H
E-mail
THIS APPLICATION PACKAGE WILL NOT BE ACCEPTED BY THE
APPLICABLE ITEMS LISTED BELOW -ARE -INCLUDED WITH -THE
REQUIRED ITEMS:
UNLESS ALL OF THE
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 of North 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. ne.gov/about/divisions/water-resources/water-resources-permits/wastewater-branch/npdes-wastewater-permits

Submitter Change Request Form — (Addlupdate users)
North Carolina Electronic Discharge Monitoring Report System
bmsbn of % ter iisames
EDMR registered Owners may use this form to add or update eDMR users to the NCDWR's Electronic
Discharge Monitoring Report system. If the Organization is not currently registered for eDMR, then the
Owner or designated Responsible Official will need to complete the required eDMR Registration Form
(available from the eDMR website) and submit it to the NCDWR eDMR Administrator at the address
below.
Type of Request (please select):
Add Submitter Permissions: (See Section B)
Update Submitter Permissions: (See Section B)
To add or update eDMR user permissions, please provide the following information:
Section A: Owner Information
NAIR
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OWN
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nt
fit, 2
Section B: Activate New Submitter or Update Existing User
Please complete the Submitter User Details on page 2 for the individuals who will need Submitter —
permissions or to update Submitter details, such as adding additional permits, to an existing user.
Submitter permissions can only be assigned by the NCDWR eDMR Administrator. Note: The Owner
and Facility Administrator can deactivate or delete eDMR user permissions for any individual within
its organization, including Submitter permissions.
Discharge Monitoring Report. The Submitter must be an individual with delegated signatory authority
for the Owner/Organization. If individuals: other than the Responsible Official for the Owner have been
delegated signatory authority, the Division of Water Resources must be notified in writing of such
delegations. A delegation of authority form is available from the eDMR website.
In addition to the User Details, please specify the NPDES permit(s) that each user will be associated with
for eDMR submittal. Should additional space be needed for users and/or permits, please make additional
copies of the Submitter User Details page and complete as needed.
NCDWR eDMR Submitter Change Request Form -ver. 1.0 Page 1

Date:
Wastewater Branch
Water Quality Permitting Section
Division of Water Resources
1617 Mail Service Center
Raleigh, NC 27699-1617
Subject: Delegation of Signature Authority
Facility Name:
NPDES Permit Number: N I C f o I o I Z I IS I {o IS I
To Whom It May Concern:
By notice of this letter, l hereby delegate signatory authority to each of the following individuals for all
punnn trcarions, nisctt rge monitoring reports, ancdimeter in ormation relating tote 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 213.0506.
Individual #1 Individual #2 (if applicable)
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If you have any questions regarding this letter, please feel free to contact me at either the phone
number or email address below.
Sincerely,
Authorized Signing Official's Signature
".fit UOLUdl2 pa„o V
:d Signing Official's �Name (typeorprint) Title J
D Pz,ry 5U-�, NIP � ,i
orcl
33Co - SaLA-41t i 33(P -13c- 401 S
Office Phone Mobile Phone
cc: 40 �S615M Regional Office, Water Quality Permitting Section
(Enter region name)

Responsible Official Authorization
The Responsible Official, as identified in accordance with 40 CFR 122.22, is the appropriate individual
with th`eI authority to sign reports for the organization.
I, v 1 ua�� (printed name), have the authority to make this request for
( own CW 1 v118u.`V (Owner/Organization Name).
I request the NCDWR add or update the eDMR Submitter user permission(s) as indicated above on the
Submitter User Details page.
l� Maw)
SianafiwP __ T;tl.--_..
Please return the completed form to the NCDWR eDMR Administrator via:
Fax: or E-mail:
[phone] eDMRadminaa ncdenr gov
or Mail to:
Information Processing Unit
Attn: eDMR Registration
1617 Mail Service Center
Raleigh, NC 27699-1617
NCDWR eDMR Submitter Change Request Form — ver.1.0 Page 3

Water Pollution Control System Operator Designation Form
WPCSOCC
NCAC 15A 8G .0201
Permittee Owner/Officer Name:
Call•
Mailing Address: Pc 6" �; k-AS
City:.. Q"(5UR- State: IVY- Zip: 2_73Ap Phone #: 'S34P- 8Z4-'- 4411 /
Email address:
Signature:y.�-� AW& , ja�'R Date: 11 I.�fil
.............................................................................................................................................
FacilityName: �_7�;/} A) OP P&M f eU2 Permit #:
County; I�lrt"
Facility Type/Grade (CHECK ONLY ONE):
Biological Collection Physical/Chemical Surface Irrigation Land Application
....................................................
Operator in Responsible Charge (ORC)
Print Full Name:Terr- Che e". Lewall-eki Email: +ALtg)let.. &4-owr,,aegwl5ec+r_tnr.5
Certificate Type / Grade / Number: W W 7M / I5$ F3 Work Phone #: 336- 8 zi-39 3 j
C /2�E' //
Signature:` , /�+r/ Date: %f iZ000i
"I certify that I agree to my designation as the Operator in Responsible Charge for the facility noted. 1 understand and will abide by the rules
and regulations pertaining to the responsibilities of the ORC as set forth in I SA NCAC 08G .0204 and failing to do so can result in Disciplinary
Actions by the Water Pollution Control System Operators Certification Commission."
.............................................................................................................................................
Back -Up Operatorin Responsible Charge (BU ORC) nn
Print Full Name: Wlliioy Email: W Solwl+'aa f od c-444. net
Certificate Type / Grade / Number: —= CIS S-36-D Work Phone #: 331P- ` (0S'— o? 68
Signature: — Date: t i so 17.0 2-a
"I certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. I understand and will abide by the
rules and regulations pertaining to the responsibilities of the BU ORC as set forth in 15A NCAC 08G .0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
..............................................................................................................................................
Mail, fax or email the WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 Fax: [phone]
orke:'naIto: fiaii :c4­tailiefiiottedeuro€av
Mail or fax a cony to the
appropriate Regional Office:
Asheville
2090 US Hwy 70
Swannanoa 28778
Fax: [phone]
Phone: [phone]
Washington
943 Washington Sq Mall
Washington 27889
Fax: [phone]
Phone: [phone]
Fayetteville
225 Green St
Suite 714
Fayetteville 28301-5043
Fax: [phone]
Phone: [phone]
Wilmington
127 Cardinal Dr
Wilmington 28405-2845
Fax: 910,350.2004
Phone: [phone]
Mooresville
610 E Center Ave
Suite 301
Mooresville 28115
Fax: [phone]
Phone: [phone]
Winston-Salem
450 W. Hanes Mall Rd
Winston-Salem 27105
Fax: [phone]
Phone: [phone]
Raleigh
3800 Barrett Dr
Raleigh 27609
Fax: [phone]
Phone:[phone]
a'�1Lt.
Revised 05-2015
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