WQ0042555_Owner (Name Change)_20211214

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State of North Carolina
Department of Environmental Quality
D Division of Water Resources
R SEWER SYSTEM PERMIT OWNERSHIP/NAME CHANGE
Division of Water Resources INSTRUCTIONS FOR FORM:PNOCF 01-16
I. EXISTING PERMITTEE INFORMATION:
1. Permittee's name:Decks to Sea,LLC
2. Signature authority's name:Jesse Zimmer per 15A NCAC 02T.0106(b)
3. Signature authority's title:Member
4. Permittee's mailing address: 157 Scrub Oaks Dr.
City:Hampstead State:NC Zip:28443-_
5. Permittee's contact information: Phone number:[phone] Fax Number( )_-
Email Address: 189topsailroadna,gmail.com
IL APPLICANT INFORMATION:
ECEI lUl E
1. Applicant's name: Nirbhay N. Singh
2. Signature authority'sNirbeay N'Spe91
I5A NCAC 02T.0106(b) DEC 1'4 2021
3. Signature authority's title: Member NCDEQ/DWR/NPDES
4. Applicant's mailing address: 6829 MacTavish Way
City: Raleigh State: NC Zip: 27613
5. Applicant's contact information: Phone number:( 3394270 Fax Number GA_
Email Address: [e-mail]
6. Representative's name:
7. Representative's title:
8. Representative's contact information Phone number:( )__ Fax Number( ) -
Email Email Address:
III. PERMIT INFORMATION:
1. Existing permit number:WQ0042555 and most recent issuance date:June 15,2021
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? I Yes or❑No
FORM:PNOCF 01-16 Page 1 of 2

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IV. CERTIFICATIONS:
Existing Permittee's Certification per 15A NCAC 02T.0106(b):
I,Jesse Zimmer 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.
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Signature: ae00b4 11/0921 4:55 PM EST
KSMT-ZBLH-2CHE-CEAW Date: 11/9/2021
Applicant's Certificatio
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nper 15A NCAC 02T.0106(b):
I, / 1 f� (/V• S/ 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 as civil penalties up to$25,000 per violation.
Signature: 712fA 6(rAyIfU, Date: f (2.-S/
20 2. I
FORM:PNOCF 01-16 Page 2 of 2