NC0040711_Owner Name Change_20161229

Pat McCrory
Governor
NIMA RECEIVENINCDE01OR
�® DEC 2 9 2016
NCDENR Water Quality,
North Carolina Department of Environment and Natural Resources Permitting Section
Division of Water Resources
Donald R. van der Vaart
WATER QUALITY PERMITTING SECTION
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.
Secretary
I. NPDES Permit No. (for which the change is requested): N C 0
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or
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Certificate of Coverage #:
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H. Existing Permittee Information:
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a. Permit issued to (company name):
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b. Person legally responsible for permit:
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Last
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Permit Holder Mailing Address
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.c. Facility name:
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d. Facility's physical address:
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City State
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e. Facility contact person:
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Phone
III. Applicant Information:
a. Request for change is a result of -
If other please explain:
b. Permit issued to (company name):
c. Person legally responsible for permit:
❑ Change in ownership of the.facility
Name change of the facility -or owner '
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Page 1 of 2 Revised 7/01/2014

d. Facility name: r4w
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e. Facility's physical address: Ky
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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 shall 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 cliange 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):
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 CERTIFICATION
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.
1,6
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

Date: ( Z— ("1-1 (a
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: U S A - ,Lt- c,
NPDES Permit Number: N I C 10 10 1 µ 1 01-7 I 111 1
To Whom It May Concern:
By notice of this letter, I hereby delegate signatory authority to each of the following individuals for all
permit applications, discharge monitoring reports, and other information relating to the 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 2B.0506.
Individual #1 Individual #2 (if applicable)
Name:
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Title:
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Mailing Address:
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Physical Address:
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Email Address:
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Office Phone:
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Mobile Phone:
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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 S' ng Officia '
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Authorized Signing Official's Name (type orprint) Title
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Mailing Address
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Email Address
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Office Phone Mobile Phone
cc: P-A14u, H Regional Office, Water Quality Permitting Section
(Enter region name)