NCG110078_Name-Owner Change Form_4/17/2018

Environmental
Quakry
I. Permit Information
I. Please enter the permit number for which the change is requested.
NPDES Stormwater Individual Permit #:
NC
SX
XX
XX
X
-OR-
General Permit Certificate of Coverage (COC) #:
NCG110078
Use this link to check the permit contact information that is currently in our database.

II. Permit Status
11. Permit status prior to requested change.
a. Permit issued to: City Of Oxford
ConpanyWre
b. Person legally responsible for permit:
First name:* Middle name: Last name:*
Amy Ratliff
Title: City Engineer
Permit holder's mailing address:* Street Address
PO Box 506
Address Line 2
City of Oxford WW -FP
City
State / Rovince / Fbgion
Oxford
NC
Fbstal / Zip Code
Country
27565
US
Phone #:*
919
603-
1113
c. Facility name:*
d. Facility address:*
Fax #:
City Of Oxford WWTP
Street Address
325 New Commerce Dr
Address Line 2
City of Oxford wwtp
City State / F rovince / Pegion
Oxford NC
Fbstal / Zip Code Country
27565 United States
e. Facility contact person (prior to change, optional):
First name: Middle name: Last name:
Dennis Wilson
Phone #: [phone]

III. Requested Change Information
111. Please provide the following for the requested change (revised permit).
a. Request for changes is a result r Change in ownership of facility
of: * r Name Change of the facility or owner
b. Permit to be issued to: City Of Oxford
Corrpany Nacre
c. Person to be legally responsible for permit:
First name:* Middle name: Last name:*
Amy Ratliff
Title: City Engineer
Permit holder's mailing address:* Street Address
PO Box 506
Address Line 2
aty State / Province / Fbgion
Oxford NC
Wstal / Zip Code Country
27565 United States
Phone #:* Email address:*
919- aratliff@
603- oxfordnc.
1113 org
d. Faciltiy name:* City Of Oxford WWTP
Is the FACILITY contact different than the person legally responsible
above?*
r Yes
f No
f. Facility contact person:
First name:*
Dennis
Phone #:*
Middle name
919 691-1520
Email address:* [e-mail]
Last name:*
Wilson

IV. Permit Contact Information
Is the PERMIT contact different than the person legally responsible
above?
r Yes
r No
IV. Permit contact information
(if different form the person legally responsible for the permt)
.................................................................................................................................................................................
First Name:*
Middle Last Name:*
Dennis
Name: Wilson
Title:
WWTP Superintendent
Mailing Address:*
Street Address
325 New Commerce Dr
Address Line 2
oty
Oxford
Fbstal / Zip Code
27565
Phone #:* 9196911520
Email Address:* [e-mail]
State / Rovince / Fbgion
North Carolina
Country
United States

V. Permit Facility Activities
V. Will the permitted facility continue to conduct the SAME industrial activities conducted prior to this
ownership or name change:*
r Yes
r No

VI. Signature
In the case of an ownership change request, certifications must be signed by both the permit holder
prior to the change and the new applicant. For a name change request, the signed Permittee's
Certification is sufficient.
This completed application is required for both name change and/or ownership change requests.
North Carolina General Statute 143 - 215.6 b (i) provides that:
Any person who knowingly makes any false statement, representation, or certification in any application, record, report, plan, or
other document filed or required to be maintained under this Article or a rule implementing this Article; or who knowingly makes a
false statement of a material fact in a rulemaking proceeding or contested case under this Article; or who falsifies, tampers with, or
knowingly renders inaccurate any recording or monitoring device or method required to be operated or maintained under this Article
or rules of the [Environmental Management] Commission implementing this Article shall be guilty of a Class 2 misdemeanor which
may include a fine not to exceed ten thousand dollars ($10,000).
Permittee Certification: I attest that this application for a name and/or 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, or if all required supporting information is not included, this application will be considered incomplete.
Permittee Signature
671�311�P�'ec
FLrrrit-holder prior to the ownership change, or permt-holder authorizing the narre change
Will another person need to complete or sign this form before it can be submitted? No problem! Simply CLICK
the "Save as Draft" button below and send the URL link to the other party to access the form. Questions? Call Laura
Alexander at [phone] or e-mail her at [e-mail].

Initial Review
Project ID:* NCG110078