NC0021253_Owner (Affiliation Change)_20210520

ROY COOPER
N
Governor
MICHAEL S. REGAN
Secretary
LINDA CULPEPPER
Water Resources rnler,nl n„ecrur
ENVIRONMENTAL QUALITY
PERMIT NAME/OWNERSHIP CHANGE FORM J
I. CURRENT PERMIT INFORMATION: REC 11/, ,�
Permit Number: NC00 . / l / 1 / 5 I 3 or NCG5 / / / i�,,i,�' 2 0 2021
1. Facility Name: C 4}) 0 f 1-3G v e J o c )( w T P NCDEQ/DWR/NPDEs
II. NEW OWNER/NAME INFORMATION:
1. This request for a name change is a result of:
a. Change in ownership of property/company
/ b. Name change only
V c. Other(please explain): On an Jc n reap os"S,eJe O•F1 G 1 G I
2. New owner's name (name to be put on permit):
3. New owner's or signing official's name and title: w 1 11 L e ti/)-5
(Person legally responsible for permit)
./'1cryor
(Title)
4. Mailing address: 6-01/ernYn ey1+C41 .4V e✓ City: Pc-4 ve)G c IC
State: AC Zip Code: -2'r5 Phone: ( Z5Z ) 6-9-00
E-mail address: iN 1_ e w,-S ) u Ve/0 c/C i C, U 5
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:
1. 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]
State of North Carolina I Environmental Quality I Water Resources
1617 Mail Service Center I Raleigh,NC 27699-1617
919 807 6300 919-807-6389 FAX
http s://deq.nc.gov/ab out/divisions/water-resources/water-resources-permits/wastewater-branch/np des-wastewater-permits

NPDES Name&Ownership Change
Page 2 of 2
Applicant's Certification:
I, WI f 1)GCh'. L. Lev/is Jr , 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 required supporting information and attachments are not included, this application
package will be returned as incomplete.
Signature: 2, 5 Date: *I/P--1/
THE COMPLETED APPI ATION PACKAGE, INCLUDING ALL SUPPORTING
INFORMATION & MAT 'IALS, SHOULD BE SENT TO THE FOLLOWING ADDDRESS:
NC DEQ / DWR / NPDES
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Version 11/2017

14. Agree to report,within 24 hours of discovery, any evidence of discrepancy between any electronic
document I have signed and submitted and what the NCDWR eDMR has received from me by
contacting the NCDWR eDMR Administrator via email at eDMRadmin cr,ncdenr.gov.
15. Understand that the NCDWR eDMR's system will automatically reject any electronic document
submitted without a valid electronic signature if such signature is required.
16. Agree to contact the NCDWR eDMR Administrator via email at eDMRadmin(iincdenr.gov within
ten working days if my duties change and I no longer need to interact with eDMR on behalf of my
organization.
17. Agree to notify the NCDWR eDMR Administrator via email at [e-mail] if I cease
to represent the regulated entity specified above as signatory of that organization's electronic
submissions as soon as this change in relationship occurs.
18. Understand that the NCDWR may contact the Organization's Responsible Official,who signs below
to authorize me as a signatory for the Owner/Organization, in order to verify my identity.
19. Agree to retain a copy of this signed agreement as long as I continue to represent the regulated entity
specified above as signatory of the Organization's electronic submissions.
20. Certify that I have the authority to enter into this Agreement on behalf of the Organization identified
above, and I am a signatory authorized to represent that Organization, and I am able to sign and
submit reports and other information on behalf of that Organization in the capacity required by statute
and/or regulation.
C. Permit/Facility Information
Approval under this Electronic Signature Agreement is applicable to the following permits and if
applicable to the Submitters, if noted here and in Section E:
Permit
Number' Facility Name Facility Address Submitter2(if applicable)
Ai 001-11-5 3 Cob oic II vj)®ck tvivr 3 o k 5a c kcson r eF-Crey Su rmri h
, 400)5131 Brawn 81vd tivrP 51-7 tvebl aivd Oa BBcmehw('y
c004-67S Brow Blvd ( 'r? S)2) IA6,6 p Ited Pav;d l zrn ►va%
1. You may only include permits associated with One owner. If more space is needed for additional permits or submitters you
may attach separate pages. A supplemental sheet is available at:httns://deq.nc.aov/about/divisions/water- -
resources/edmr/forms-and-reports
2. A separate Section E must be included for each Submitter in order to obtain a hard copy signature and notarization for all
entities. If more than one individual will have submitter permissions for the same permit,then indicate this on separate
rows.
NCDWR Electronic Submittal Agreement Version 1 Page 3

D. Responsible Official Signature
The Responsible Official, as identified in accordance with 40 CFR 122.22, is the appropriate individual
with the authority to sign and submit reports for the organization.
I, 1n//1 h a h2 L- Lew Ji'S Jr. (printed name),have the authority to enter into this
Agreement for C'i ri D,F' Have Jo c,� (Owner/Organization Name).
I request the NCDWR grant me and,if included in Sections C and E of this form, the named Submitter(s),
an electronic signature credential to submit and accept documents electronically on behalf of my
organization.
I acknowledge that I, and the individual(s)named in Sections C and E(if applicable),work at/for my
organization and have authority to submit and accept electronic documents and act as a signatory for
purposes of the NCDWR's electronic document systems.
By submitting this application,I, `V,///21y1 I. Lekoil Jr (printed name),have read,
understand, and accept the terms and conditions of this Electronic Signature Agreement. I certify under
penalty of law that I have personally examined and am familiar with the information submitted in this
application and all attachments and that,based on my inquiry of those persons immediately responsible
for obtaining the information contained in the application,I believe that the information is true, accurate
and complete. I am aware that there are significant penalties for submitting false information,including
the possibility of fine and imprisonment.
' v l a l7 v' S// /a1
Responsible()file. Signature Title Date
14/jewi5F cwe1ockt)c.1,{S g 607- 0-0./-& /---hni
Email Address Phone Number
*email will be the primary method of contact for the electronic submittal process so it is important to have an accurate email
available at all times
If you are a current eDMR submitter please provide your User Id:
User Id
Subscribed and sworn to before me this //q yy
4day of /)4/ , 20 0'--) .
`,o 11 O 14 Signature of Notary Public
ocriARY
6/7. K j'y4V)
pUBUC V Printed Na the of Notary Public
•
CO
isto°iiss•�v My Commission Expires: /J/J5/02-
(SEAL)
NCDWR Electronic Submittal Agreement Version 1 Page 4

r
E. Submitter Signature
The Submitter(electronic signature applicant) is a user other than the Responsible Official who submits
this agreement to request to sign reports electronically. The Submitter is given signatory authority by an
individual identified as the Responsible Official by the Owner/Organization to sign reports and other
information and to accept electronic documents.
yil (printed name), am authorized by the Responsible Official
name in this docut,who does have the authority under the applicable standards, to enter into this
agreement for Ci 0-I itave/0 Gf (Owner/Organization Name).
By submitting this application,I, J.e Are y D h. (printed name),have read,
understand, and accept the terms and conditions of this Electronic Signature Agreement. I certify under
penalty of law that I have personally examined and am familiar with the information submitted in this
application and all attachments and that,based on my inquiry of those persons immediately responsible
for obtaining the information contained in the application, I believe that the information is true, accurate
and complete. I am aware that there are significant penalties for submitting false information, including
the possibility of fine and imprisonment.
0 X-- C_. 5-7/ /
S m ter ignat Title Date
111 r/ nlifc4 36D 6ma CGrr, ?,f — 33.6 — 7
Email Address Phone Number
*email will be the primary method of contact for the electronic submittal process so it is important to have an accurate email
available at all times
If you are a current eDMR submitter please provide your User Id: �2. ,c.K‘7!J 7`73
User Id
Subscribed and sworn to before me this I q day of / ( _ , 20 21 .
``` ®R i. o Signature of ary Public
:° OSARY "f�
l et 12
ugh,\ ' / Printed Name of Notary Public
P
freN
0 •
My Commission Expires: J fj/)Jr/d-
(SEAL)
NCDWR Electronic Submittal Agreement Version 1 Page 5

4' J
N.C. Department of Environmental Quality
Division of Water 'esourees
Electronic Signature Agreement
Federal regulations require that electronic documents must have valid electronic signatures if Title 40 of
the Code of Federal Regulations requires handwritten signatures on the paper documents they replace.
Valid electronic signature refers to an electronic signature on an electronic document that has been
created with an electronic signature credential.
This Electronic Signature Agreement, when finalized and approved,will allow the individuals with
electronic signature credentials to sign electronically a variety of required permit documents in lieu of the
submittal of signed paper copies. The submittal of Electronic Discharge Monitoring Reports (eDMR)
will be available once your electronic signature credentials are in place. Some agreements for document
submittals or acceptance, as noted in the Agreement Conditions (Section B.), are not currently available
electronically but are included here to have the agreements in place and to avoid the need to complete
future submittal of agreement forms when these systems are initiated.
A. Owner/ Organization Information
Owner/Organization Name: C:41 o.f 148,✓e,l o c is LA" P
Responsible Official: ;a-
Street -�
(as identified in accordance with 40 CFR 122.22) VV
Address: U r';x1Yvi&Pt tcA d A a,c,
City: 1146,v &i c,c.dC
State/Zip: N C.
Phone Number: (2$2) e' dg 'tGa
Email Address:
*email will be the primary method of contact for the electronic p o W v i i.r+ c
submittal process so it is important to have an accurate email 4/+✓ i
available at all times
B. Agreement Conditions
To receive and accept the required electronic signature credential, consisting of a user name and
password,issued by the North Carolina Division of Water Resources (NCDWR) in order to sign
electronic documents submitted to NCDWR's Electronic Document Systems and to receive electronic
documents from NCDWR's systems;
The Responsible Official and Submitter(if applicable)named in this form do herby:
1. Understand that this Electronic Signature Agreement requires me to submit electronic documents to
NCDWR's approved eDMR system under the authorized program in lieu of paper submissions.
2. Understand that this Electronic Signature Agreement requires me to accept electronic transmissions,
in lieu of paper transmissions of all peiuuits,permit modifications, authorizations to construct,and
any other correspondence related to reviewing and processing permits from NCDWR. This
authorization will not become effective until NCDWR establishes a system for processing electronic
documents;I am notified in writing from NCDWR that use of the electronic systems has officially
been initiated; and North Carolina rules and statutes are changed to allow the implementation of
electronic submittal and acceptance of documents.
NCDWR Electronic Submittal Agreement Version 1 Page 1