NC0020231_Owner (Name Change)_20220211

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NC DEPARTMENT OF ENVIRONMENTAL QUALITY
1 ,' DIVISION OF WATER RESOURCES
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1 WATER QUALITY PERMITTING SECTION
NORTH CAROLINA NPDES PERMITTING
Environmental Quality
PERMIT NAME/OWNERSHIP CHANGE FORM
INFORMATION:I. CURRENT PERMIT
Permit Number: NCO() 2/0/2/3/1_ or NCG5 / / / /_
1. Facility Name: Louisburg Water Reclamation Facility
II. NEW OWNER/NAME INFORMATION:
1. This request for a name change is a result of: RECEIVED
a. Change in ownership of property/company FEB 1 1 2022
_X_b. Name change only NCDEQIDWR/NPDES
c. Other(please explain):_
2. New owner's name (name to be put on permit):
Christo h eal
3. New owner's or signing official's name and title:
(Person legally responsibl for permit)
Mayor
(Title)
4. Mailing address: 110 West Nash Street City: Louisburg
State: NC_ Zip Code: 27549 Phone: (919) 496-3406
E-mail address: [e-mail]
III. FACILITY AND DISCHARGE INFORMATION
1. Will the waste stream for the facility remain the same as under the previous owner? Yes X No 0
2. Will the treatment system and discharge location remain the same? Yes X No 0
"No Responses"
If either or both of these questions are answered"No"then more information will be needed to review the
request. Please attach documentation to describe and explain the changes to the facility activities, waste
stream, treatment process or outfall location. The Division may not be able to process the Permit
Name/Ownership Change request and may require that the new owner file a new permit application.
�U North Carolina Department of Environmental Quality I Division of Water Quality
.4." 512 North Salisbury Streete 1617 Mail Service Center Raleigh,North Carolina 27699-1617

NPDES Name and Ownership Change
Page 2 of 2
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)
3. Information to document facility, waste stream,treatment system or outfall changes as noted in
item III above (if appropriate)
Applicant's Certification:
I, Jimmy Ellington , 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. I understand that Permit Name/Ownership Change can only take place through
action taken by the Divi ion of Water Resources and that no actions on my part or the part of my
company result in the tomatic transfer of permit coverage.
Signature: Date:
THE COMPLETED APPLICATION PACKAGE, INCLUDING ALL SUPPORTING INFORMATION & MATERIALS,
SHOULD BE SENT TO THE FOLLOWING ADDDRESS:
NC DEQ/ DWR/ NPDES
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Version 07/2021