WQ0032475_Owner (Name Change)_20191210

State of North Carolina
R Department of Environmental Quality
Division of Water Resources
.�*� SEWER SYSTEM PERMIT OWNERSHIPINAME CHANGE
Division of Water Resources INSTRUCTIONS FOR FORM: PNOCF 01-16
I. EXISTING PERMITTEE INFORMATION
I. Permittee's name: City of Northwest
2. Signature authority's name: James Knox per t5A NCAC 02T .0106tb1
3. Signature authority's title: Mayor
4. Permittee's mailing address: 4889 Vernon Road
City: Northwest State: NC Zip: 28451•�
5. Permittee's contact information: Phone number: (2-WO) 655-3110 Fax Number ( )
Email Address: citvclerk(alcitvofnorthwest corn
11. APPLICANT INFORMATION:
I. Applicant's name: Brunswick Coun(y Public Utilities
2. Signature authority's name: John Nichols per 15A N
3. Signature authority's title: Director of Public Utilities
4. Applicant's mailing address: P.O Box 249
City: Bolivia State: NC Zip: 28422-,
5. Applicant's contact information: Phone number: (2- O) 253-2653 Fax Number (9 t� MS -4305
Email Address:john.nichols(&brunswickcouniync.it
6. Representative's name:
7. Representative's title:
8. Representative's contact information Phone number: (___) _-_ Fax Number (-
Email Address:
III. PERMIT INFORMATION:
1. Existing permit number: W00032475 and most recent issuance date: March 7. 2016
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 I SA NCAC 02T OLL6-9 ® Yes or ❑ No
FORM: PNOCF01-16 Page I oft

IV. CERTIFICATIONS:
Permittee's Certification per 15A NCAC 02T.01061b):
s f�. Y,nou Ma,
(Signature Authority's
& title from Application Item 1.2 & 3)
that this application
has been reviewed by me and is accurate and complete to the best of my knowledge. 1 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. 1 will also make no claim against the Division of Water Resources should a condition of the existing permit
be violated. 1 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 143.215.613 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.
Signature: �t& A 1(iar R' Date:
7
Applicant's Certification per 15A NCAC 02T.0106(b):
John Nichols attest that this application
(Signature Authority's name & title from Application Item I1.2&3.)
has been reviewed by me and is accurate and complete to the best of my knowledge. 1 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. 1 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 as ' .1 pe 1 'e up to $25,000 per violation.
Signature: Date: 11 /27/2019
FORM: PNOCF 01-16 Page 2 of 2