NC0038831_Owner Name Change_20161228

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Inc,°
December 28, 2016
NC DEQ — Division of Water Resources
Water Quality Permitting Section
1617 Mail Service Center
Raleigh NC 27699-1617
Re: Ownership Name Change Request
NCO064734 — Bradfield Farms
NCO058378 — Elk River
NCO038831— Carolina Trace
NCO024295 — Connestee Falls No. 1
NCO088943 — Connestee Falls No. 2
NCO033111— Fairfield Harbour
NCO022985 — Fairfield Sapphire
To Whom It Will Concern,
PECEIVEDUDENWR
DEC 2 9 2016
Water Quality
Permitting Section
Please find enclosed Permit Ownership change request forms for the above referenced NPDES discharge
facilities. There is a name change of the owner due to a merger consolidation of our smaller affiliates into Carolina
Water Service, Inc. of North Carolina. Proof of merger documentation filed with the NC Dept. of the Secretary of
State is affixed to each request.
If you should have any questions or need any additional information, please feel free to contact me at 704-319-0517
or by email at [e-mail].
Thank you for your attention.
Sing ly,
A
LLA-C-�
Martin Lashua
Vice President of Operations
AUtItes, Inc wmpany Carolina Water Service, Inc. of North Carolina
P.O. Box 240908 0 Charlotte, NC 28224 0 P 704-525-7990 0 F: 704-525-8174
5701 Westpark Dr., Sude 101 i Charlotte, NC 28217 0 www.uiwater com

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NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Resources
Pat McCrory
Governor WATER QUALITY PERMITTING SECTION
John E. Skvarla, III
Secretary
PERMIT NAME/OWNERSHIP CHANGE REQUEST
This form is for ownership changes or name changes of NPDES wastewater permits.
• "Permittee" references the existing peinnt holder
• "Applicant" ieierences the entity applying foi the owneiship/name change
I. NPDES Permit No. (for which the change is requested): N C 0 0 3 8 8 3 1
or
Certificate of Coverage #:
F _NC G 5
II. Existing Permittee Information:
a Pernut issued to (company name)
Carolina Trace Utilities, Inc.
b Person legally responsible for permit
Matthew Klein
First MI Last
President
RECEIVEORMEDDINP,
PO BoxTitle
DEC 2 9 2016
Permit Holder Mailing Address
Charlotte NC 28227-0908
Water Quality
City State Zip
Permitting Section
[phone] [phone]
Phone Fax
e Facility name
Carolina Trace Wastewater Treatment Plant
d Facility's physical address
5448 Cox Mill Road
Address
Sanford NC 27332 -
City State Zip
e Facility contact person
Danny Lassiter [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 th®-fas'��r-owner
If other please explain Name change of owner due to merger consolidation
b Permit issued to (company name)
Carolina Water Service, Inc. of North Carolina
c Person legally responsible for permit
Matthew Klein
First MI Last
President
Title
PO Box 240908
Permit Holder Mailing Address
Charlotte NC 28224-0908
City State Zip
[phone] dwlasstter@utwater com
Phone E-mail Address
Page 1 of 2
Revised 7101/1014

d Facility name
e Facility's physical address
f Facility contact person
Address
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?
® Yes
❑ No (please explain)
If applicable, the applicant shall submit a mayor permit modification request to DWR A mayor 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:
This completed application is required for both name change and/or ownership change requests
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 (Pernut holder prior to ownership change)
I, Martin Lashua, 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
r quired su portin formation is not included, this application package will be returned as incomplete
ut CPPS 12/28/2016
Signature Date
APPLICANT CERTIFICATION
I, Martin Lashua, attest that this application for a name/ownership change has been reviewed and is accurate and complete
to the best f my knowledge I u erstand that if all required parts of this application are not completed and that if all
require s porta infor atio is of included, this application package will be returned as incomplete
12/28/2016
Signature
xxxxx:<:<xxxxxxxxxxxxxx;� txxx
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

NORTH CAROLINA
Department of the Secretary of State
To all whom these presents shall come, Greetings:
I, ELAINE F. MARSHALL, Secretary of State of the State of North
Carolina, do hereby certify the following and hereto attached to be a true copy of
ARTICLES OF MERGER
OF
BRADFIELD FARMS WATER COMPANY
CAROLINA TRACE - UTILITIES, INC.
CWS SYSTEMS, INC.
ELK RIVER UTILITIES, INC.
TRANSYLVANIA UTILITIES, INC.
INTO
CAROLINA WATER SERVICE, INC. OF NORTH CAROLINA
the original of which was filed in this office on the 30th day of August, 2016.
Scan to verify online.
Certification# C201624300754-1 Reference# C201624300754-1
Verify this certificate online at http://www.sosnc.gov/verification
IN WITNESS WHEREOF, I have hereunto set
my hand and affixed my official seal at the City
of Raleigh, this 31st day of August, 2016.
Secretary of State