WQ0040683_Application_20191203

State of North Carolina
Department of Environmental Quality
DWR Division of Water Resources
SEWER SYSTEM PERMIT OWNERSHIP/NAME CHANGE
Division of Water Resources INSTRUCTIONS FOR FORM: PNOCF 01-16
This form is for ownership changes or name changes of a sewer system permit. Please note that "Permittee" references the
existing permit holder, and that "Applicant" references the entity applying for the ownership/name change.
Sewer permits start with a WQ or WQCS and contain the terms sewer extension or collection system in the subject field. This
form should not be used for permits with NC, NCG, SW or other types of non -sewer permits beginning with WQ.
For more information, visit the Division's Water Quality Permitting s website:
A. Sewer System Permit Ownership/Name Change (FORM: PNOCF 01-16) Application (All Applications):
® Submit an original completed and appropriately executed application (PNOCF 01-16).
® The Existing Permittee's Certification shall be signed in accordance with 15A NCAC 02T .0106(b). Per 15A NCAC 02T
.0106(c), an alternate person may be designated as the signing official if a delegation letter is provided from a person who
meets the criteria in 15A NCAC 02T .0106(b).
® The Applicant's Certification shall be signed in accordance with 15A NCAC 02T .0106(b). Per 15A NCAC 02T .0106(c), an
alternate person may be designated as the signing official if a delegation letter is provided from a person who meets the criteria
in 15A NCAC 02T .0106(b).
B. Existing Permit (All Applications):
® Submit a copy of the most recently issued permit and certification.
C. Property Ownership Documentation (All Applications):
➢ The Applicant shall demonstrate they are the owner of all property containing the sewer system facilities:
® Legal documentation of ownership (i.e., GIS, deed, article of incorporation, or contract), or
❑ Written notarized intent to purchase agreement signed by both parties with a plat or survey map, or
❑ Approved board minutes
D. Certificate of Public Convenience and Necessity (All Applications where the Applicant is a Privately -Owned Public Utility):
❑ Per 15A NCAC 02T .0115(a)(1), provide one copy of the Certificate of Public Convenience and Necessity from the North
Carolina Utilities Commission demonstrating the Applicant is authorized to hold the utility franchise for the area to be served
by the non -discharge system.
E. Operational Agreements (Applications where the Applicant is a Home/Property Owners' Association or Developer of lots to be
sold):
➢ Home/Property Owners' Associations
❑ Per 15A NCAC 02T .0115(c), submit an original properly executed Operational Agreement (FORM: HOA).
❑ Per 15A NCAC 02T .0115(c), submit an original proposed or approved Articles of Incorporation, Declarations and By-
laws that contain the language required by the Operational Agreement.
➢ Developers of lots to be sold
❑ Per 15A NCAC 02T .0115(b), submit an original of the properly executed Operational Agreement (FORM: DEW
F. Package Submitted in Duplicate
® Submit a copy of all required documents in Instructions A-E as required
THE COMPLETED APPLICATION AND SUPPORTING DOCUMENTATION SHALL BE SUBMITTED IN DUPLICATE
TO:
NCDEQ - DWR
Water Quality Permitting Section
PERCS Unit
By U.S. Postal Service: By Courier/Special Delivery:
1617 MAIL SERVICE CENTER 512 N. SALISBURY ST.
RALEIGH, NORTH CAROLINA 27699-1636 SUITE 925
RALEIGH, NORTH CAROLINA 27604
TELEPHONE NUMBER: [phone]
INSTRUCTIONS FOR APPLICATION PNOCF 01-16 Page 1 of 1

State of North Carolina
Department of Environmental Quality
DWR -00" Division of Water Resources
SEWER SYSTEM PERMIT OWNERSHIP/NAME CHANGE
Division of Water Resources INSTRUCTIONS FOR FORM: PNOCF 01-16
I. EXISTING PERMITTEE INFORMATION:
1. Permittee's name: Nishant, LTD Quality Inn
2. Signature authority's name: Neil Patel per 15A NCAC 02T .0106(b)
3. Signature authority's title: Owner
4. Permittee's mailing address: 101 Plaza Parkway
City: Lexington State: NC Zip: 27292-
5. Permittee's contact information: Phone number: [phone] Fax Number (_)
Email Address: patelneil2003kyahoo.com
II. APPLICANT INFORMATION:
1. Applicant's name: City of Lexington
2. Signature authority's name: Roger Jones per 15A NCAC 02T .0106(b)
3. Signature authority's title: Public Services Manager
4. Applicant's mailing address: 28 West Center Street
City: Lexington State: NC Zip: 27292-
5. Applicant's contact information: Phone number: [phone] Fax Number (_)
Email Address: rdiones&lexin tg onnc.gov
6. Representative's name:
7. Representative's title:
8. Representative's contact information
III. PERMIT INFORMATION:
Phone number: (_) _-
Email Address:
Fax Number (_) _-
1. Existing permit number: W00040683 and most recent issuance date: September 27, 2019
2. Reason for the permit application: Change of Ownership If other, attach detailed explanation
3. Has the facility been constructed? ® Yes or ❑ No
4. Has the facility been certified per 15A NCAC 02T .0116? ® Yes or ❑ No
FORM: PNOCF 01-16 Page 1 of

IV. CERTIFICATIONS:
Existing Permittee's Certification per 15A NCAC 02T .0106(b):
I, Neil Patel Owner attest that this application
(Signature Authority's name & title from Application Item I.2 & 3)
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that prior to reissuance of the permit
into the Applicant's name, I will continue to be responsible for compliance with the current permit and any discharge of wastewater
from this system to surface waters or the land may result in an enforcement action that may include civil penalties, injunctive relief,
and/or criminal prosecution. I will also make no claim against the Division of Water Resources should a condition of the existing permit
be violated. I also understand that if all required parts of this application are note completed and that if all required supporting
information and attachments are not included, this application will be returned to me as incomplete.
NOTE — In accordance with General Statutes 143-215.6A and 143-215.6B, any person who knowingly makes any false statement,
representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may include a fine not to
exceed $10,000 as well as civil penalties up to $25,000 per violation. I
Signature: �.i .l ✓�w1' Date: L 2 A0 I
Applicant's Certification per 15A NCAC 02T .0106(b):
I, Roper Jones, Public Services Manager attest that this application
(Signature Authority's name & title from Application Item II.2&3.)
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that after issuance of the permit into
the Applicant's name, I will be responsible for compliance with the issued permit and any discharge of wastewater from this non -
discharge system to surface waters or the land may result in an enforcement action that may include civil penalties, injunctive relief,
and/or criminal prosecution. I will make no claim against the Division of Water Resources should a condition of this permit be violated.
I also understand that if all required parts of this application package are not completed and that if all required supporting information
and attachments are not included, this application package will be returned to me as incomplete.
NOTE — In accordance with General Statutes 143-215.6A and 143-215.6B, any person who knowingly makes any false statement,
representation, or certification in any application package shall be guilty of a Class 2 misdemeanor, which may include a fine not to
exceed $10,000 as well a ivil penalties up t $25,000 per violation.
Signature: aJ 7 Date: 2 Zzol
9
FORM: PNOCF 01-16 Page 2 of 2

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