NC0021865_Owner (Name Change)_20150318

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NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Resources
Pat McCrory Donald R.van der Vaart
Governor WATER QUALITY PERMITTING SECTION Secretary
PERMIT NAME/OWNERSHIP CHANGE REQUEST
This form is for ownership changes or name changes of NPDES wastewater permits.
• "Permittee"references the existing permit holder
• "Applicant"references the entity applying for the ownership/name change.
I. NPDES Permit No.(for which the change is requested): N C 0 0 2 1 8 6 5
or
Certificate of Coverage#: N C G 5
H. Existing Permittee Information:
a. Permit issued to(company name): Town Of Chadbourn
b. Person legally responsible for permit: Patricia Garrell
First MI Last
Interim Town Manager/Finance Officer/Town Clerk
Title
RECEIVEDIDENRIDWR 602 N. Brown St.
Permit Holder Mailing Address
�t .t 8 2015 Chadboum NC 28431-
City State Zip
Water Quality [phone] [phone]
Permitting Section Phone Fax
c. Facility name: Chadbourn Wastewater Treatment Plant
d. Facility's physical address: 5275 Chadboum Hwy
Address
Chadbourn NC 28431-
City State Zip
e. Facility contact person: Daniel C Ward [phone]
First / MI / Last Phone
III. Applicant Information:
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): Town Of Chadbourn
c. Person legally responsible for permit: Robert Jones
First MI Last
Town Manager
Title
602 N. Brown St.
Permit Holder Mailing Address
Chadbourn NC 28431-
City State Zip
[phone] [e-mail]
Phone E-mail Address
Page 1 of 2 Revised 7/01/2014

d. Facility name: Chadbourn Wastewater Treatment Plant
e. Facility's physical address: 5275 Chadbourn Hwy .
Address
Chadbourn NC 28431- ,
City State Zip
f. Facility contact person:' Daniel C Ward
First MI Last
Wastewater Treatment Plant ORC
Title
[phone] [e-mail]
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?
® Yes
❑ No(please explain)
If applicable,the applicant shalj submit a major permit modification request to DWR.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.
V. 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,Patricia Garrell,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.
(---—--a41/1 u.4J 3//040/.'
Signature Date
APPLICANT CERTIFICATION
I,Robert Jones,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
ort •• formation is not included,this application package will be returned as incomplete.
' 4,0/20/4.5---
Signature Date
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
Page 2 of 2 Revised 7/01/2014