NC0062553_Signature Authority_20140309

LWIWA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Resources
Pat McCrory Donald R. van tier Vaart
Governor WATER DUALITY PERMITTING SECTION Secretary
This form is for ownership changes or name changes of NPDES wastewater permits.
• "Pennittee" references the existing permit holder
• "Applicant" references the entity applying for the ownership/name change.
I. NPDES Permit No. (for which the change is requested): NCO
or
Certificate of Coverage tt:
N C G S
IL Existing Permittee Information:
a. Permit issued to (company name):
wade k�amo}r--, -i 0 JN
b. Person legally responsible for permit:
d `tT
.SFYI i l
First MI Last
Title
-2a —J!�M
&Z2a
Permit Holder Mailing Address
C�nkier_S
Nr o'? 1-7
",-
city State Zip --
Phone Fax
c. Facility name:
Mal Hn `fps lr' C11 1 k 1aarp
d. Facility's physical address:
h f C 1 t w{
IV CI
Ad
1�5 -11-�
e. Facility contact person:
1 s nJ 8
City State Zip
%f, —A-jr-. V ,4.l..
Fins / MI / Last Photo
III. 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):
Wnd Q ()tAl InP Ir',1�CC
c. Person legally responsible for permit:
,/
iJ Q to �� E C-
First Mi Last T—
�' /
(. d fV1
1 rn r
�Q G)c Tide
Permit Holder Mailing Address
C�!„,rt-T
&; -4-7)7
state
T,Rh 743 -q,?7S- poaSzip
.,�
Phone E-mail Address
Pane 1 of z
Rgmsed 7/01,7014

d. Facility name:
e. Facility's physical address:
E Facility contact person:
(W -7Ya76- ? qi- 11h, "El)�TNY'
Phone E-mail Address 1.,
K1Ih1 �oG
IV. Will the permitted racility continue to conduct the same commercia tindnstrial activities conducted prior to
this ership or oame change?
Yes
❑ No (please ordain)
If applicable, the applicant shall submit a au jor permit modification request to DWR. A major modificatim shall be
defined as one that increases the vohmx, increases the polkaot koad, results m a significant relocation of the
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:
l . This completed application is required for both tame 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 sale) is
required for an ownership change request. Articles of incorporation are rtot sufficient for an ownership change.
AFpiicabk regotlatiarrs� AQ CFR 122.41, 40 CFR 122.61 and ISA NCAC 02H .0114
.................................................
The certifications below must be completed and signed by ¢glh the permit holder prior to the change (Permittee), and the
new applicant m the can of an ownership change request. For a name change requast, the signed Applicant's Certification
is sufficient.
PERMITTEE CERTIFICATION (Permit holder prior to ownership change):
1, attest that this application for a narnelownerthip change ban been reviewed and is aeoraate and compiete to Ilan beat
of ray 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
APPLICANT CERTIFICATION
1, .attest that this application for a namelownership change has been reviewed and is accurate and complete to the best
of my knowledge. I understand that if all required parts of this appiicatiat are not completed and that if all required
supporting
information is not included, this application package will be returned as Wcomplett.
S*anan Date
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PLEASE SEND THE COMPLETE APPLICATION PACKAGE TO:
Division of Water Resources
Wow Quality PamiWng Section
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
NPDES PERMCf NAMFJOWNERSHIP CHANGE REQUEST
Page 2 M 2 Rewhwd MlaO t

Date: •a I a5I I S
Wastewater Branch
Water Quality Permitting Section
Division of Water Resources
1617 Mail Service Center
Raleigh, NC 27699-1617
Subject: Delegation of Signature Authority
Facility Name: Pi-�jTTY-x r-SQ1 CJI1Fs-VVWT?
NPDES Permit Number: N i C ao iU z nj 5 it l
To Whom It May Concern:
By notice of this letter, I hereby delegate signatory authority to each of the following individuals for all
permit applications, discharge monitoring reports, and other information relating to the operations at
the subject facility as required by all applicable federal state, and local environmental agencies
specifically with the requirements for signatory authority as specified in 15A NCAC 2B.0506.
Individual #1 Individual 92 ef—di,..AY i
s w � Yyr. •v� c - &.,aIL
`�'13iyg►ca�Addt�,��
�..Lv75 5 1C1nd—DriVC.
rtTrenr)i�5uwn2�
Emit address,
�Offc,C,40ne;
If you have any questions regarding this letter, please feel free to contact me at either the phone
number or email address below.
Sincerely
Authorized Signing Official's Signature
A lh�3 tJZYc• ��Y...
Authorized Si ing icial's Name (t)w opiril Title
f •� r �l 2.d to C-Ct.o hr OIL s L) C- 7 i
Mailing Address
i) poA S6t
Email Address if I`
? L� .--(4 ri
Office Phone Mobile Phone
cc: 1 Regional Office, Water Quality Permitting Swtion
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