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HomeMy WebLinkAboutNC0020338_Owner (Name Change)_20150223 A .� RECEIVED/DENR/DWR �� FEB 2 3 2015 NCDENR Water Quality North Carolina Department of Environment and Natural Resourle€s itting section 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 NPUES 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 0 3 3 8 or Certificate of Coverage#: N C G 5 II. Existing Permittee Information: a. Permit issued to(company name): Town of Yadkinville b. Person legally responsible for permit: Christopher Ong First MI Last Town Mangaer Title 213 Van Buren St Permit Holder Mailing Address Yadkinville NC 27055 City State Zip (336)679-8732 (336)679-6151 Phone Fax c. Facility name: Town of Yadkinville WWTP d. Facility's physical address: 1620 Fred Hinshaw Rd Address Yadkinville NC 27055 City State Zip e. Facility contact person: Grant F. Trivette (336) 679-2184 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 Yadkinville c. Person legally responsible for permit: Perry L Williams First MI Last Town Manager Title 213 Van Buren St. Permit Holder Mailing Address Yadkinville NC 27055- City State Zip (336) 679-8732 pwilliams@yadkinville.org Phone E-mail Address Page I oft Revised 7/01/2014 1, d. Facility name: Town of Yadkinville WWTP I e. Facility's physical address: 1620 Fred Hinshaw Rd. Address Yadkinville NC 27055- City State Zip f. Facility contact person: Grant F Trivette First MI Last WWTP ORC Title (336)679-2184 gtrivette®yadkinville.org 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 0 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 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,Christopher Ong,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 s porting information is not included,this application package will be returned as incomplete. • ..Z./1 -11 I(=e - Signature Date APPLICANT CERTIFICATION I,Perry Williams,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 req ' ed supporting information is not included,this application package will be returned as incomplete. r ,A2/1 ,--- .....„..„7/ 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