NC0047562_City Manager Change_20170227

09/08/2014 08:38 9104860707
NC DENR PAGE 02/06
Pat McCrory
Govemar
AWA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Resources
WATER QUALITY PERMITTING SECTION
tgIONN
John E. Skvarla, 111
Secretary
This foi m is for ownership changes or name chi nges of NPDES wastewater permits.
• "Permittee" references the existing permit holder
• "App_licant" references the entity applying For the ownership/name change.
I. NPDES Permit No. (for which the change is requested):
or
Certificate of Coverage #:
ZI. Existing Permittee information:
a Permit issued to (company name):
b. Person legally responsible for permit:
c. Facility name:
d Facility's physical address:
e. Facility contact person:
III. Applicant Information:
a. Request for change is a result of.:
If other please explain:
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111 Change in ownership of the facility
Tame change of the facility or pwner.,
b. Permit issued to (company name):
c. Person legally responsible for permit:
C
First MI Last
C a�a i Title
?r Y
Permit Holder Mailing Address
City �} State Zip
Phone E-riail Address
Revised 7/01/2014

09/08/2014 08:38 9104860707
NC DENR PAGE 03/06
d. Facility name:
e_ Facility's physical address:
.f_ Facility contact person:
Address
LVC 3Lf
City State Zip
First MI Last
Title \ -
Phone E-mail Address
IV. Will the permitted facility continue to conduct the same commercial/industrial activities conducted prior to
this ownership or name change?
[i/Yes
❑ No (please explain)
V.
If applicable, the applicant shall submit a major permit modification request to D W R. A major modification shall be
defined as one that increases the volume, increases the pollutant load, results in a significant relocation of the
discharge point, or results in a change in the characteristics of the waste generated.
Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS ARE
INCOMPLETE OR MISSING:
1. This completed application is required for both name change and/or ownership change requests.
2. 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.
Applicable regulations: 40 CFR 122.41., 40 CFR 122.61 and 15A NCAC 02H .0114
The certifications below must be completed and signed by both the permit holder prior to the change (Permittee), 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 CERTTFICAT8ON
rPno ha �/a
I, this
of my .o led:e. I understand
supp f_ in !' • is not in
or a name
t if all req
ded, this
wnership change has been reviewed and is accurate and complete to the best
fired parts of this application arc not completed and that if all required
pplication package will be returned as incomplete.
02- 2 .1D%7
Date
Signature
PLEASE SEND THE COMPLETE APPLICATION PACKAGE TO:
Division of Water Resources
Water Quality Permitting Section
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
.NPDES PERMIT.NAME/OWNERSHIP CHANGE REQUEST
Revised 7/01/2014