NC0021601_Ownership Change_20141208

Pat McCrory
Governor
A�
NCDEN
North Carolina Department of Environment and Natural Resources
Division of Water Resources
WATER QUALITY PERMITTING SECTION
John E. Skvarla, III
Secretary
PERMIT NAME/OWNERSHIP CHANGE REQUEST
This form is for ownership changes or name changes of NPDES wastewater permits.
" Permittee" references the existing permit holder
e "Applicant" references rile entity applying for the own ershiphi time change.
I. NPDES Permit No. (for which the change is requested):
FN C 0 0 2 1 6 0 1
or
Certificate of Coverage #:
N C G S
11. Existing Permittee Information:
a. Permit issued to (company name):
Town of Tryon
b. Person legally responsible for permit.
Jim
Fatland
First
Ml Last
Town Manager
RECEIVED/DENR/DWR
Title
301 N. Trade Street
DEC — 8 2014
Permit Holder Mailing Address
Tryon
NC 28782-
Water Quality
city
State Zip
Permitting Section
[phone] [phone]
Phone
Fax
c. Facility name:
Tryon Wastewater Plant
d. Facility's physical address:
1526 E. Howard Street
Address
Tryon
NC 28782-
City
State Zip
e. Facility contact person:
Deborah M. Bradley [phone]
First I MI / Last Phone
M. Applicant Information:
a. Request for change is a result of: ❑ Change in ownership of the facility
® Name change of the facility or owner
If other please explain:
b. Permit issued to (company name):
c. Person legally responsible for permit:
Town of Tryon
Joey
_
Davis
First
Ml
Town Manager
Last
Title
301 N. Trade Street
Tryon
Permit Holder Mailing Address
NC 28782-
City State
[phone] tryommng'�,atryon-nc.com
Zip
Phone
E-mail Address
_
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d. Facility name: Tryon Wastewater Plant
e. Fact] ity'sphysical address: 15261- Howard Street
Address
Tryon NC 28782-
City Starve Zip
f. Facility contact person: Deborah M Bradley
First MI Last
ORC
Title
828 859-5626 [e-mail]
Phone Ismail Address
IV. Will the permitted facility continue to conduct the same commerciallindustrial activities conducted prior to
this ownership or name change?
® 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 of the
discharge point, or results in a change in the characteristics of the waste generated.
V. Required Items: TfUS APPLICATION WiLL BE RETURNED UNPROCESSED IF ITEMS ARE
INCOMPLETE OR MISSING:
l - This completed application is required for both name change andfor ownership change requests.
2. Legal documentation of the transfer of ownership (such as relevant pages of a contract deed, or a bill of sale) is
required for an ownership change request. Articles of incorporation are not sufficient for an ownership change.
Applicable regulations: 40 CFR 122.41, 40 CFR 122.61 and 15A NCAC 02H .0114
The certifications below must be completed and signed by both the permit holder priorto the change (Permittee), and the
new applicant in The case of an ownership change request. For a name change request, the signed Applicant's Certification
is sufficient.
PERMITTEE CERTIFICATION (Permit holder prior to ownership change):
i, Joey Davis, attest that this application for a namelownership change has been reviewed and is accurate and complete to
the best of my knowledge. 1 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.
Signature Date
APPLICAI\'C CERTIFICATION
1, Joey Davis, 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.
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
NPDES PERMIT NAME/OWNERSHIP CHANGE REQUEST
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