NC0072877_Owner Name Change_20141105

PERMIT NAME/OWNERSHIP CHANGE REQUEST
•
L NPDES Permit No.(for which the change is N C 0 0 7 2 8 7 7
requested): WQ0010470
H. Existing Persittee Information:
• Permit issued to(company name): Town of Newton Grove
• Person legally responsible for
permit: Gerald W. Darden
First MI Last
RECEIVEDIDENRIDWR Mayor
Title
NOV 0 7 2014 P.O.Box 48
Permit Holder Mailing Address
Water Quality
Permitting Sectlon Newton Grove NC 28366
City tate Zip
( 910 ) 594-0827 ( 910)236-9018 I
Phone I Fax
• Facility name: Town of Newton Grove POTW
• Facility's physical address Pork Chop Hill Road
Address
Newton Grove NC 28366
_ City tate Zip
• Facility contact person Jim Ballance ( 910) 591-7871
First / MI / Last Phone
HI. Applicant I.feratatioa:
• Request for change is a result of
Name change of the facility or owner
If please
erlgaiff-
• Permit issued to(company
name):
• Person legally responsible for
permit: Barbara F. Burch
First iI Last
Title: Mayor
P.O. Box 4

Permit Holder Mailing Address
Newton
Grove NC 28366
City tate Zip
( 910)594-
0827
Phone E-mail Address
• Facility name: Town of Newton Grove POTW
• Facility's physical address: Pork Chop Hill Road
Address
Newton Grove NC 28366
City tate Zip
• Facility contact person: Jim Ballance
First SII Last
ORC
Title
( 910)591-
7871 [e-mail]
Phone E-mail Address
IV. Will the permitted facility tontine to conduct the save commerciaUindastrial activities conducted
prior to this ownership or name change?
X Yes
No(please
explain)
If applicable,the applicant shall submit a major permit modification request to DWR.A major modification
shall be defined as one that increases the volume,increases the pollutant load,results in a significant
relocation ofthe discharge point,or results in a change in the characteristics of the waste generated.
V. Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS ARE
INCOMPLETE OR MISSING:
1. This completed application is required for both name change and/or ownership change requests.
2. Legal documentation of the transfer of ownership(such as relevant pages of a contract deed,or a bill of
is required for an ownership change request. Articles of incorporation are not sufficient for an ownersh
change.
Applicable regulations:40 CFR 122.41,40 CFR 122.61 and 1 SA NCAC 02H.0114
The certifications below must be completed and signed by both the permit holder prior to the change(Permittee),
and the new applicant in the case of an ownership change request. For a name change request,t1q.fired
Applicant's Certification is sufficient.
PERMITTEE CERTIFICATION(Permit holder irior to ownership change):
I, Gerald W.Darden ,attest that this application for 1t 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 is not included,this application package will be
returned as incomplete.
� — //' /V
Signature Signature Date
APPLICANT CERTIFICATION
I, Barbara F.Burch ,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 is not included,this application package will be
returned as incomplete.
CliLhat40 • W '•- ( 0)41
Signature Date
****************„******
PLEASE SEND THE COMPLETE APPLICATION PACKAGE TO:
Division of Water Resources
Water Quality Permitting Section
1617 Mail Service Center
Raleigh,North Carolina 27699-1617