NC0037176_renewal application_20201207

I arillty Blame:
WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM
NCAC 15A 8G .0201
TALI to Navigate Forme
t � d xItwl ()u, TrO44W ed Perm.lit# N OM7176
Facility Type: WW
Permittee OwnerfOfficerName:
Email Address: i 1
Permittee Signature:
Facility Grade: 11 SUBMIT SEPARATE FORM FOR EACH CLASSIFICATION
x
Gir rv,�'t
ORC
Operator in Responsible Charge
Nale-
date{ 1?— /06 zo
Full Name: DAVISJAMES work Phone: 828-$97-006
Email Address. OFFICE JJEMf,NET — —
CertificateType: Ww_ Certificate Grade: II Certificate3#: 9974
63
Signature: Effective Date:
"t certify that I agree to my desfgnotko os the Operator in Responsfble Charge for the facrlfty rrated. I ufiderMnd and wilt
ublde by the rules arad regulations pertairrirrg to the rgsporisIbilitfes of the ORC as set forth in 15A NCAC 086 .0204 and
faiiing to do so can result in Oi 6plinoryAct+wrs by the Water PoWfutfarr Corrtro� System Operators Certifrcatian Cffrx mission.'
Backtip ORC
Full darns: .SHA[VNON JAMS work Phone. [phone]
Certificate Type: WW Certificate Grade; jI Certifir-ate #; 100 526
S�gnatufe: Effective Date:
"I certify th Pt f agree to my designation as a.Back-up txperatar In Responsibfe Charge for the focfky noted. I understand mid W11
abide by the rules and regOations pertafningr to the respansibfiMes of the ORC Qs set faonh fry 2 5A NCAC 08G A204 and fafling to
da so can resuft fn Dfscfpflnary Acttorrs by the Water P}olluttan Control System Operators Cere ftotforr Corr missfon_"
Backup ORC
Full dame; JUANITA JAMES Work Phone: [phone]
Certificate Type: WW Certificate Grade: I Il Certificate #; 20474
Signature: Effective Date:
"f certify that I agree to my &mfg iaffon as o Back-up Operator fir Responsfble Charge for the f vdIrty noted f un*rstun d and will
Obfde by the rules Qnd regUIG Orts pertaining to the responsibfiitres of the ORC ffs set forth in 25A NCAC 08G .0204 and failin g to do
so Corr resuftin D5CiplrnaryActions by the water Controf system Operators Cerrificatforr Cot►]rnfs bn."
MalI, fax or email OI;IGINALto: b KSOCC, 3.619 Mail Service C2rlter, Raleigh, NC 27699-163.8 1 FAX, 919-715-2726 Icertadmin @ncdenr.gov
Mail br fax a CCUPY to; Ashevilie-2090 US Hwy 70, Atisheville, NO 287781 FAX: [phone] r FH, 828-2964&W
RQ Viyed $f�0 *

Page 2
Facility Name.
Bakckup ORC
Permit M N 0037176
Gulf N3rno:
Work Rhona;
CertifIcate Type.
WW Certificate Grade-, II Certificate #:
Signature:
Eff active Date:
I certfy that l agrec to my designation as a Rock -up operator fn Responsible Charge for the facility rioted. t understand art$ will
abide by the rules and regufatfons pentalnfng to the resyarrsibffirfes of the ORC as set forth to 154 NC4C 03 .0204 and fa kng to
do so can result in OiscipMarV Actions by the water Pollution Control Systems Operohars CertificoVon mmfsstora_"
Backup ORC
Full Name:
Work Phone{
t ficate Type;
WW Certificate Grade: ii Certificate M.
Signature=
Effective Date:
"J certify that; agree to my designatia n as a Back-up operator fin ffiespo risible Charge far the facility mated, i unilerx#ond an4 will
abide by the rules Gnat regufatio ns pertcirrir?4 to the responsibifi ties of the OAC as set forth fA 1 S4 NCA t= 086 _0204 and ifofling to
do So Can result in DfsCfplfnafyActfons by the Water Pollutfon Control System Operators Ceftrfiration Gommission,"
Backup ORC
Full Name;
Work Phone=
Certificate Type..WW
Certificate Grade: 11 Certificate #:
Signature:
Effective Gate:
"l certify that l agree to tray designotforr as a Hock -up Operator In ftsponsfble Charge for the faCifitY rioted l undersrmd arrdl W11
obfde dry the rotes c rrd regufutlorrs pertaining to the responVbflttles of lire ORC as set forth In 25A MUC O86a ,0204 and faAtng to
dam so cart mewltin Disciplinary Actions by the Water Polfutian Con trot System Operators Certification Cornmfssion,"
Backup ORC
Full Name:
Work Phone,
Certificate Type:
VVW Certificate Grade; Certificate #;
Signature; Effective Date:
"l certify that � agree to Fay designathm as a gack•up Opera#orin Resparnsfble Charge for the facility noted_ l understand and will
abide by the rules and regulations yerYbirain to the msponsibifi tle5 of the QK- as Set forth in 154 NCAC O8* , 02,04 and failing to
do so con result In McIpflrtary Actions by the Water FOution Control System Operators Ceftificatibn Commission."

ROY COOPER
MICHAEL S. REGAN
LINDA CULPEPPER
Water Reso[jrc(,s
1r4wjPo vcArAL QUAL,Tv
PERMIT NAME/OWNERSHIP CHANGE FORM
I. CURRENT PERMIT INFORMATION:
Permit Numl)ar; N c op 3 1 7 1I1-1 1 or N C O
1, Facility fume: OI !Q� I
II. NEW OWNERMAME INFORMATION:
1. This request for a name change is a result of:
a. Change in owniaml3lp of pF0perty1WMpany
fib. Narr[e change only
o_ Other (please explain):
2. New owners flame (name to be put on permit):
3. New owner's or signing official's name and title: 1� - I ]
(Person tog aIIy responsible for permd )
4 Or
(Tine)
4. Mailing address:_?, l iay' t^ r � C'
state: W1 - Zip Code -
E-mall address: W I I �Nr Fll%l�t."7 I --)roar Y+-,L 2�- C f) '+,
THIS APPLICATION PACKAGE WILL NOT BE ACCEPTED BY THE DIVISION UNLESS ALL OF THE
APPLICABLE ITEMS LISTED BELOW ARE INCLUDED WITH THE SUBMITTAL.
REQUIRED ITEMS:
I . This completed application form
2. Legal documentation of the transfer of ownership (such as a property deed, articles of
incorporation, or sales agreement)
[see reverse side of this page for signature requirements]
Sue ofNorih Carolina 111 iuiMnUIL-nMi QLu11iiv I Water Rc�aureLr
1617 Mail 5ervict Colter I Raleigh_ NC 27699-1617
L)19 07 6300 919-807-6389 FAX
hqs /deq,nc.govlahMi/divisin�rsJti� l r-resnnrC lvwptet=re+ri��r�es��wtrritilti?u rslextiu� r-bruit;3�lrpslc -wuh[ wal�r-p�'rrnir

NPDES Name & Owntrship Change
Pap 2at2
Applicants Certification:
11 Hake" , attest that this application for a
name/ownership change has been raviewod and is accurate and complete to the hest of my
knowledge. 1 understand that if all required parts of this application are nct completed and that
if all required supporting information and attachments are not included. this application
package will be returned as incomplete,
Signature. (�— A -t' pate.
THE COMPLETED APPLICATION PACKAGE, INCLUDING ALL SUPPORTING
INFORMATION & MATERIALS, SHOULD BE SENT TO THE FOLLOW NG ADDDRESS:
NC DECK 1 DWR J NPOES
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Version 1112017

jNPDES .APPLICATION - FO12Ei D
For ; rAvaldl :-awned tree nlent s}'deems treatin g 100dlo donicraile wm mtrw mterb -1.0 W-1)
Mnil the eomplele appiieatloo ta;
. V, DEN 11 � DivLgion of Water Quuliry I NPUS Ivnil
1617 Mail Service ('enter, Rnlelgh, AC 27699L-1 617
NPUS Peirnit NOW37176
!f}aia one czwlP ctrlrg Mim form r+r c*mpul;wr xse rho 7'-W kay or lhi: up down orrnws Ia nrom from awficid 1,9 the +a d. Tv
check Ow Ames. dfd }mr mmem rue rr�p of the hnx. th"ise. p4afeprintor "e.
1. C ontarl NA-Mlaukm; ]
Owner ti uu;r C/L �D f lL rFi €.�.y[ L �q
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Te[epl7ono u:YlirCr ` 2 Ica
Fax Numbar
IL
e-mail Address T V `I I ,% + m L a c-L) m
Localluo orf ciflty prodadngdlscharge:
wheel( here ji'smna address as aha+-e ❑
Strw .kddrass or lgmw R«ad LID i 3i I (f� o j
3. Operator lnfor matieni
Marx of rhn flm puNle orgngratton ar o0wr amen}' dhrir opwrnrur the facilftyr (Nati rhar thla Jr naf nfernng to the Upuratur
in flesp(msWe G" or ORC)
Nmne
Mai Iing Addrem
;hate i 44) Cudc
TcicThonc Number
Fax dumber
e-mail Address
4, lkxcriporak nr++Lksueacoter
Pncill��. GfnerJtin Q li°11loreR�,ltrr/Cilet k ul1 rha! gppF� l:
lndusuia] irhnlSc713CF.ruploVOOS ..
Ur11r}lm]rrCi:d Y NUmkTelfFMPl0 cos
Ri, sidwial N.umbar of }lamas
Sthcml lwumhornf glLm36 l;L?Smfr

()rli+sr Explain; Nur-King T{nme
17csor3De 123C sow s) of WasleW
Mirmil R'm u111j'
N_Umt1CT nt �t"rtiUfRti HCrti`CLI:
nter (csamp]o: sut division, mobile hz nie pnrk, sfiWping crnlor%, Te%LzurF,ls, de):
,+rrCarlj4ylluutiwytew
S4TuKlc (sanilwy sowor only) Combined (storm savor and san ilary sewer)
b. OlPtrrll Initnr'MWtlaut;
Numberof.everale dbchoru polnrs �I
Uulfull ]dcntlficAllnrt rtumlWr[s)
Is the rrulrall equlppcd wiIli it diffuser': Ycit \ Yv
;. ti a me 0, rceeild me stmim(s) (WV uaidiruirts` Prcrupde a rnup rowing flee crwi k5worr ofowk ordffalP.-
,Lllen llranch nNhe French flrverE Rl r Bnsln
9.FrrgnencrofDiwh"gr. X L'vhilntwus ]nietmltiml
I r 3n1crmittcre1:
Davy; pep week diselsargr 01!cLcs.; rlur9tiOn:
9. Deacrl4e the t reatntenf system
L?m n?? , astnileul caonpavrsMts, orshddittg 42*WAes_ jOiWide daD_Qra Jf'h12
.nrwce j7runc1ed,.s not serfelenr, crrtach FAe dimeriprian of The Finaimenr sy'sfem in a separate sheetay'pnper,
A OXW16 �IG1) rncillty with moauul har Perm, arrallon MRin with dual hlivwQn pmAing difF Lid air,
happered rlaritSerwith &Uninmr Lind sludge returns. Iablrt ehlorinalion, vhlnrine ronllret husln, twblrl
declllnrinarltHl, effluent pnntp smFjnm,
11). F'l+3w 1n#+rrnuftl�n=
Trrximtmt Pianr F1tslan naw MGD
An nu al AVrrn$!r dully M W-1) { lrrr ncc previous 3 yenn)
.)Iuxlnuuii dadly n4a% NIC;D (foPt1K previmm 3 years)
12, It lhia iracit€ly lo*xated an ]ndlart coruttr+'?
Ycs Y No
12. F.lfluent Data
-NEI :IPFLIQI 7t'.FFCA'1dcacmefori`rWpawrroretsharae.1'vccL!Culifworr.Zen wumwrdpHsAShcbegrubswJufes.JbFuffuehEr
p%:wa&4mrs 244kuu comprdrte saopieng ahai! be .vsed If afore fb,rra one orndysrj u rK rg racparr d'aih' MMTMu,ro Wrd Rmnr&5' z VruWE_
tft7mly0� pn,L�Ysrx rs imp, Lid., wpait as Lrty 01,W,ru,n.
RFAFR'a L 4PPL7C4.NTS, Provide the highasr su{gte reading and. {antMY rts,erage Mw' the past M
mein0i r frrJ, ;Vrtrarlu ?0tC raWMAI'lu 111 Miry rWymrt A lark orH�pr nnrmnolorr
Pa ramaler
Deily
Mai`L" }
Unlls of Measuremmr
r asknum
A%'era r
Fiia6mivalO.,cygelsD4•mand(DOB.)
20.2
12.1
M0.1
FG!6:al Colifunu
ii011
83.1
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M2
1 17 6
G-1
Li�teper�i]5r4�5umsnter}
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empamiaue (%Venter)
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7.1
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13_ Lim all prrmll*, euunirurllrm appn-%w14 midlur uppliewtlunc.
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I 'it' (%I)NVA) [kean1)Mfkl dIMMIA1
NTIDCS NCOM7176 Dm4c or R (Sec000 404 or CWA )
PliCi(CA:t) � I'loher
1w+m•miislmmm program (AAA)
PCrndI Numkwr
[ crrHry Mat tam fwmlliarwith the infonwition CPWAncd in tfiae nppN<411rm Mtid 0Wt 141113V hrd ofmykn+ewledg!rand
hellefsuch infumiritinnIN live, cam plvte,und uccurek.
& I, F�
Pruned name of Person Signing
c
S ipmALure o r A pplivan L
NMJr (`.arollina Ocner4 $Latutp ]1]- k5,6 JVAI) stales: A Tw pmum wire knm`ms)M makes my false slatemeet repreaertubark or
=&ticsllon Ln am' APpti cs iQf4 record, rcpoq lrlaN or AKT document file& or required la tv maieraincd under Ariide 21 or rcguLoo Dens of
dh Fmiroe=WAL Manegcmtru Com.n;aik" intpLctrecnti,i4 rhal Anide< ar wha feleilled, eampers with, or knuwingly rrndere iaaecuralo
any recording or mmTr Ic ing device or m,eLhod ragtared 4o Im opumud at Fru nlahwd under ArriiLC 21 w rCphliom of the LnLlramneeral
MAf1*rmenl C4mmissi Dn ifM14C ARg Ihs1 .1w ide. shaL1 he aly of a iydmd rncam w punishable by a tine not to cxecrd S? %OK tw by
impriummenr nai ro oxsced six n► man. or by holh. (1 R U.S.C.. lleclion Wn L pmviaLem a peero,l,mcnr Ivy a Zinc of nil nrrm 4Qgt $2$.Mp a(
imrriy{mmeur nw W3rc rhan S YOM, arNth. li4 z ■iNilar C4 MC-.)
I co'.1 L1+13