WQ0043790_Owner (Affiliation Change)_20230309

State of North Carolina
Department of Environmental Quality
Division of Water Resources
SEWER SYSTEM PERMIT OWNERSHIP/NAME CHANGE
INSTRUCTIONS FOR FORM: PNOCF 01-16

FORM: PNOCF 01-16 Page 1 of 2

I. EXISTING PERMITTEE INFORMATION:

1. Permittee's name: Davidson Industrial Properties - 78 TW, LLC
2. Signature authority’s name: Jonathan Smith per 15A NCAC 02T .0106(b)
3. Signature authority’s title: Registered Agent
4. Permittee’s mailing address: 111-H Reynolda Village
City: Winston Salem State: NC Zip: 27106-
5. Permittee’s contact information: Phone number: [phone] Fax Number ( ) -
Email Address: [e-mail]

II. APPLICANT INFORMATION:

1. Applicant's name: 78 TW Alexander Owner (DE) LLC
2. Signature authority’s name: Matthew Haverty per 15A NCAC 02T .0106(b)
3. Signature authority’s title: VP Design & Construction
4. Applicant’s mailing address: 125 Summer Street,
City: Boston State: MA Zip: 02110-
5. Applicant’s contact information: Phone number: [phone] Fax Number ( ) -
Email Address: [e-mail]
6. Representative’s name: John Brack
7. Representative’s title: Sr. Design & Construction Manager
8. Representative’s contact information Phone number: [phone] Fax Number ( ) -

Email Address: [e-mail]

III. PERMIT INFORMATION:

1. Existing permit number: WQ0043709 and most recent issuance date: August 26, 2022
2. Reason for the permit application: Select 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? Yes or No







  


FORM: PNOCF 01-16 Page 2 of 2
IV. CERTIFICATIONS:

Existing Permittee's Certification per 15A NCAC 02T .0106(b):
I, 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.
Signature: Date:

Applicant's Certification per 15A NCAC 02T .0106(b):
I, 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: Date:







  

!
!

&





&


!!$
#!%


 !"!