WQ0036706_Signature Authority_20220609

ROY COOPER
Governor
MICHAEL S. REGAN
S. DANIEL SMITH
Db ector
Division of Water Resources
Non -Discharge Branch
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
To Whom It May Concern:
NORTr 'LINA
Environmental Quality
June 9, 2022
Subject: Permit No, WQ0003885
Signature Authority Designation
Town of Ahoskie
Wastewater Irrigation System
Hertford County
As an appropriate signing official for �W►� ���� �� �'J (cityltown or
business name) as designated by 15A NCAC 2T .0106, I hereby delegate authority to sign and certify all
permit applications, reports or other permit related documents to the following staff for the following
permit types (sewer, spray, land application) and/or permit numbers:
Position
Person
Currently in
Position
Permit Type
or Permit
Number
If you have any questions, please contact me at the following:
Permittee/A plic t name lease print): -ToIi��arx H o � ; a r d
Title: i I 6.G 1 3 Je'
Compli;te mailing address: 18.01 80
City:
Telephone number:
Sincerely,
-
7-1
L
Y
signature
(U2, ) 9-07-5-45-/
North Carolina Department of Environmental Quala%, i Division of water Resources
512 North Salisbury Sheer 1617 Mail Service Center Raleigh North Carolina 27n9G-1617
9I9 707.9000

State of North Carolina
DWR
Department of Environmental Quality
Division of Water Resources
NON -DISCHARGE PERMIT OWNERSHIP/NAME CHANGE
Division of Water Resources FORM: NDPONC 06-16
1. EXISTING PERMITTEE INFORMATION:
I . Permittee's name: The Honorable Jimmie Rowe
2. Signature authority's name: Jonathan Ho and per 15A NCAC 02T .0106(b} Title: chidORCJsispervisor
3. Pertnittee's mailing address: P.O. Box 767
City: Ahoskie State: NC Zip: 27910 -
4. Permittee's contact information: Phone number: (252 ) 332 - 5146 Email Address:
5. Demonstration of historical consideration for permit approval — 15A NCAC 02T .0120:
Has the Permittee or any parent, subsidiary or other affiliate exhibited the following?
a. Has been convicted of environmental crimes under Federal law or G.S. 143-215.6B? ❑ Yes or ✓❑ No
b. Has previously abandoned a wastewater treatment facility without properly closing that facility? ❑ Yes or ❑✓ No
c. Has unpaid civil penalty where all appeals have been abandoned or exhausted? ❑ Yes or P No
d. Is non -compliant with an existing non -discharge permit, settlement agreement or order? ❑ Yes or ✓❑ No
e. Has unpaid annual fees in accordance with 15A NCAC 02T .0105(e)(2)? ❑ Yes or 0 No
II. FACILITY INFORMATION:
1. Facility name: Town of Ahoskie
2. Facility's physical address: 208 Johnny Mitchell Road
City: AhosUc State: NC Zip: 27910 - County: Hertford El
III. PERMIT INFORMATION:
1. Existing permit number: WQ0003885 and most recent issuance date: 5/12/2022
2. Existing permit type: Conjunctive Reclaimed Water Utilization
3. Reason for the permit application: Name Change F1
4. Has the facility been constructed? ✓❑Yes or ❑ No
IV. APPLICANT INFORMATION:
1. Applicant's name: The Honorable Weyling White
2. Signature authority's name: Jonathan Ho and per 15A NCAC 02T .0106(b} Title: cmeroeasupmisai
3. Applicant's mailing address: P.Q. Box 76
City: Ahoskie State: NC Zip: 27,910-
4. Applicant's contact information: Phone number: (252 ) 332 - 5146 Email Address:
5. Demonstration of historical consideration for permit approval — 15A NCAC 02T .0I20:
Has the Applicant or any parent, subsidiary or other affiliate exhibited the following?
a. Has been convicted of environmental crimes under Federal law or G.S. 143-215.613? ❑ Yes or ❑✓ No
b, Has previously abandoned a wastewater treatment facility without properly closing that facility? ❑ Yes or ❑v No
c. Has unpaid civil penalty where all appeals have been abandoned or exhausted? ❑ Yes or ✓❑ No
d. Is non -compliant with an existing non -discharge pennit, settlement agreement or order? ❑ Yes or ✓❑ No
e. Has unpaid annual fees in accordance with 15A NCAC 02T .0105(e)(2)? ❑ Yes or ❑ No
FORM: NDPONC 06-16 Page 1 of 2

Existing Permittee's Certification per 15A NCAC 02T .0106 b :
I, Jonathan Ho and
attest that this application for
(Signature Authority's name & title from Application Item I.2.)
Town of Ahoskie
(Facility name from Application Item II.1.)
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that prior to reissuance of the permit
into the Applicant's name, any discharge of wastewater from this non -discharge system to surface waters or the land will 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 the existing 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 as incomplete. I further certify that the existing Permittee or any affiliate has not been convicted of an
environmental crime, has not abandoned a wastewater facility without proper closure, does not have an outstanding civil penalty where
all appeals have been exhausted or abandoned, are compliant with any active compliance schedule, and do not have any overdue annual
fees per 15A NCAC 02T _0105(e).
NOTE — In accordance with General Statutes 143-215.6A 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 penalties up to $25,000 per violation.
Signature: %Date: - Z
Applicant's Certification per 15A NCAC 02T .0106(b):
1, Jonathan Haggard attest that this application for
(Signature Authority's name & title from Application Item IV.2.)
Town of Ahoskie
(Facility name from Application Item 11.1.)
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that after reissuance of the permit
into the Applicant's name, any discharge of wastewater from this non -discharge system to surface waters or the land will 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. I further certify that the Applicant or any affiliate has not been convicted of an environmental
crime, has not abandoned a wastewater facility without proper closure, does not have an outstanding civil penalty where all appeals have
been exhausted or abandoned, are compliant with any active compliance schedule, and do not have any overdue annual fees per 15A
NCAC 02T .0105(e).
NOTE — In accordance with General Statutes 143-215.6A 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 penalties up to $2 ,000 per violation.
Signature: Date: `r'G
FORM: NDPONC 06-16 Page 2 of 2